RSVP
101 Oak Street
Poplar Bluff Missouri  63901

                                               Date _____________________

Name ___________________ Birthday __________________________

Address ___________________________________________________

City, State & Zip ____________________________________________

Phone ___________________________ e-mail ___________________

Please circle all that apply to you.  (This data is for statistical analysis with respect to the success of the Affirmative Action Program.  Submission of the information is voluntary).

    Male   Female   Black   White   Hispanic   American Indian  Handicapped

Retired from ___________________ Position _____________________

Referred to RSVP by _________________________________________

Are you currently volunteering?  Yes  No    If so, where? _____________

Method of transportation:  own car   friend   need ride

Days available:  S   M   T   W   Th   F   Sa     Time available?  A.M.   P.M.

Emergency Contact _____________________Relationship ___________

Home Phone ________________________ Work Phone _____________

Physician ___________________________ Phone # ________________

Beneficiary for RSVP insurance:

Name _________________________ Relationship __________________

Address  _______________________ Phone ______________________

City, State & Zip _____________________________________________

                                          
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