Volunteer Acknowledgment Form – Fill Out and Use This PDF

VOLUNTEER ACKNOWLEDGMENT FORM

VOLUNTEER INFORMATION

Full Name: __________________________________ Social Security #:_____________________

Gender: ___M ____F

Date of Birth: _________________ UIN# ____________________

Address: __________________________________________________________________________

City: _______________________ State/Province: ________		Zip/Postal Code: _______________
Phone: ______________________________
Ethnicity: (select only one): _____ Hispanic or Latino _____ Not Hispanic or Latino
Race: (select one or more):
_____ American Indian/Alaskan	_____ American Indian/Alaskan Native		_____Asian
_____ Black/African American	_____ Native Hawaiian/Other Pacific Islander _____White

When applicable to volunteer activities performed, please provide the following information:

Dri er’s Li e se; “tate of Issue a d Nu er __________ ________________________________

Personal Auto Insurance;

Company & Policy # ______________________________________________________________

DEPARTMENTAL AUTHORIZATION

___________________________ has volunteered to assist the _________________________

(PRINT NAME)(DEPARTMENT)

with the following activities:______________________________________________________

___________________________________________________________________ A ti ities

It is expected that Activities will be provided (dates)_______________ to __________________

for approximately ________number of hours		daily		weekly		monthly.

Representative: ______________________________Title:__________________________________

Dept Name: _________________________________Dept. Org Code #:_______________________

________________________________________________	____________________
Departmental Representative Signature	Date
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	Revised December 2009

PLEASE READ THIS INFORMATION AND CERTIFY BELOW

Florida Gulf Coast U i ersit U i ersit tha ks ou for do ati g our ti e a d e pertise

volunteering to assist the University for the Activities, Department, and dates listed on the Volunteer Acknowledgement Form (page 1). Please be advised that Florida law authorizes and encourages the University to accept the services of volunteers, and defines a volunteer as any person who, of his or her own free will, provides services with no monetary or material compensation. While acting within the scope of your university activities, as a volunteer you are covered by state sovereign immunity and

lia ilit prote tio i a orda e ith Chapter , Florida “tatutes, a d Worker’s Co pe satio i

accordance with Chapter 440, F.S., excluding the replacement of lost wages. In other words, Volunteers

are considered to be providing services on behalf of the University and are afforded liability coverage a d orker’s o pe satio o erage i the sa e a er as U i ersit e plo ees. Ho e er,

Volunteers are not entitled to unemployment compensation and are not subject to any provisions of law related to state employment. In carrying out your assigned duties and responsibilities, you are expected to report any injury you experience or any threatened claim you may become aware of as a result of your volunteer efforts. You do not have the right to make any contracts or commitments on behalf of the University. You are also expected to comply with applicable state and federal statutes, University regulations, policies and procedures, and to act under the direction of University officials and administrators. This acknowledgment form expires on June 30th of the current fiscal year and must be renewed annually.

CERTIFICATION

I, __________________________________________, hereby acknowledge that I have read and

understand the above information, and that I am acting in the capacity of a volunteer on behalf

University for purposes of the above-mentioned Activities and all Volunteer Information is accurate.

_____________________________________	_______________________
Volunteer Signature	Date

SUBMIT COMPLETED FORM TO HUMAN RESOURCES

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Revised December 2009