Volunteer Application

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
How would you identify your gender?*
- Woman
- Man
- Transgender
- Non-binary/non-conforming
- Prefer not to respond
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Work Phone

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How did you hear about Westside Pacific Villages? Please provide the name(s) of anyone who referred you.*
Are you affiliated with one of the partnering organizations? (Select all that apply)
- Westchester Rotary
- Westchestery Family YMCA
- LAX Coastal Chamber
- Covenant Presbyterian
- Culver Palms Meals on Wheels
- Drollinger Family Charitable Foundation
- Westside Pacific Villages
- Airport Marina Counseling Service
- Councilmember Mike Bonin's Office
- N/A
Are you affiliated with another local organization (service club, school, faith-based, other?)
Emergency Contact #1:*
First Name Last Name Relationship Email or Phone (required)
Emergency Contact #2:
First Name Last Name Relationship Email or Phone (required)

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Are you volunteering to be a DRIVER?*
- Yes
- No
Driver's License Number*
We will also need a copy of your drivers license.
Driver's License Expiration Date*
Date Format: MM slash DD slash YYYY
Auto Insurance Number*
Auto Insurance Expiration Date*
Date Format: MM slash DD slash YYYY
Vehicle Make/Model*
Vehicle Color*
Curb level?*
- Yes
- No
If SUV, does your vehicle have a running board?
- Yes
- No

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Availability*
Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

Please indicate the times that you are available to volunteer.
How many hours do you prefer to volunteer for per week?

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Verification*
- By selecting this box, I am indicating that I have read, understand, and agree to the following: All volunteers are subject to a background check and a current DMV report. You are required to provide a copy of your Drivers License or DMV Senior ID and proof of your current automobile insurance, with limits of liability clearly indicated. As a volunteer, you are required to attend a Westside Pacific Villages training class. Minor volunteers (age 16-18) require signed approval from a parent or legal guardian.
*
- By selecting this box, I certify that all information in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration for volunteer service and may result in my dismissal, if discovered, at a later date.
Social Security Number
Please provide your social security number here or call us to provide via telephone.
*
- By selecting this box, I hereby authorize Westside Pacific Villages, or any designated agent(s) working in their behalf, to obtain and conduct a background check and current DMV report pertaining to me.
Media Release*
- By checking this box, I hereby give my consent for Westside Pacific Villages (WPV) and its staff, clients and/or volunteer personnel to photograph me. I understand that I will not be compensated for the use of my photograph(s). I also understand that WPV will use and display my photograph(s) in a professional and dignified manner to be used for the following purposes: (1) Education and training materials for WPV membership, and (2) Marketing, media and publicity materials, e/g/ WPV website, brochures, flyers, presentations, public relation programs, social media, events and articles.

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Is the applicant a minor (under the age of 18)?*
- Yes
- No
Waiver of Liability and Hold Harmless Agreement*
I agree to the Waiver of Liability and Hold Harmless Agreement
The undersigned hereby expressly agrees to release, hold harmless, and to waive any claims, known and unknown, for loss, damage, personal injury, or otherwise, which the undersigned has or which may arise, and hereby agrees to forever release and discharge Westside Pacific Villages, its members, officers, board members, employees, successors and assigns from any such claims, known and unknown, which have resulted or may in the future result from participation in services provided to Westside Pacific Villages or its members. These services include, but are not limited to, grocery shopping, deliveries, meals, technology training, transportation, friendly visits, social events, yardwork, pet care and home maintenance. The claims waived and released include, but are not limited to, claims for medical expenses, loss of earnings, emotional distress, pain and suffering, and loss of services which the undersigned has now or may hereinafter have on account of any injuries or damages sustained by the undersigned. The claims are waived and released, REGARDLESS OF WHETHER SUCH LOSS IS CAUSED BY THE NEGLIGENCE OF Westside Pacific Villages or its members, or otherwise and regardless of whether such liability arises in tort, contract, strict liability, or otherwise, to the fullest extent allowed by law.

While WPV takes every precaution to help protect clients, volunteers and those involved with this program, it cannot prevent the spread of the coronaviurs, nor guarantee that all client requests will be met with 100% certainty. Your involvement with this free program is voluntary and taken at your own risk.

The undersigned further declares that the terms in this Waiver of Liability and Hold Harmless Agreement have been completely read and fully understood and voluntarily accepted. Furthermore, the undersigned understands that he or she covenants and promises not to sue Westside Pacific Villages for damages which may result from services provided to Westside Pacidic Villages or its members, officers, board members, employees, successors and assigns. Furthermore, this Waiver of Liability and Hold Harmless Agreement supersedes all prior representations, oral or written, and may only be modified by written agreement by and between Westside Pacific Villages and the undersigned.
Name of Applicant*
By typing my name below, I hereby agree to all of the statements above.
Today's Date*
Name of Parent or Legal Guardian*
By typing my name below, I hereby agree to all of the statements above.
Today's Date*
Name of Applicant (minor)*
By typing my name below, I hereby agree to all of the statements above.
Today's Date*
Comments
This field is for validation purposes and should be left unchanged.

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WPV Volunteer Application Form

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