River Cities Community Access Volunteer Form

Please fill out this form and return it, if you would like to volunteer at RCCA so that we may match you with something of interest to you.

Date: ___/___/____

Please print the information on this form.

NAME:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: (___) ___- WORK: (___) ____- (ok to call you at work? Y /No )

CELLULAR PHONE (___) - _____-____

OCCUPATION:

Are you: Under 18? _____ Birthday: ___/___/____

License Number_____________________________

In case of an emergency_____________________________  Ph.(____) _____ - _____

Best time to call: (shade or mark times normally available for calls)

Time MON TUE WED THU FRI SAT SUN

Before 9AM

9AM-12PM

12PM-3PM

3PM-6PM

6PM-9PM

SKILL LEVEL: (Mark all that apply)

Experience: (Mark all that apply)

Videographer: None: Beginner: Advanced:

Video Editing: None: Beginner: Advanced:

Directing: None: Beginner: Advanced:

INTERESTS: (Circle all that interest you)

Studio camera Camcorder/videographer

Floor Directing

Editing

Producing own program

School Programs

Government Meetings  

School Board Meetings

Music Events

Local sports

Community Events Parades

Other

Times available for volunteering: (shade or mark times available)

Time MON TUE WED THU FRI SAT SUN

Before 9AM

9AM-12PM

12PM-3PM

3PM-6PM

6PM-9PM

References:

Name:________________________   Phone______________________________

Name: ________________________  Phone______________________________

As a condition of volunteering, I give permission for the City of Wisconsin Rapids to conduct a review of my criminal history.  I understand that, if accepted as a volunteer, my volunteer position conditioned upon the receipt of no inappropriate information on my background.  I hereby release and agree to hold harmless from liability the City of Wisconsin Rapids, River Cities Community Access, the Telecommunications Advisory Commission, their employees, officers and volunteers, or any other person or organization that may provide such information.

Each volunteer granted access to data, records, and personal information holds a position of trust and must preserve the security and confidentiality of the information he/she uses.  Volunteers are required to abide by all applicable federal and state regulations and City of Wisconsin Rapids policies regarding confidentiality of fata, records, and information

Signature_________________________________  Date____________________________