Summary: DOCUMENTATION ON UNIVERSITY VOLUNTEERS
Many individuals offer their services to the University throughout the year as volunteers
in various capacities, and it is important to properly document when an individual is authorized
to provide volunteer services on behalf of the University of Virginia. Please use this form to
document such activities.
This form should be completed by the supervising faculty or staff member who will be
responsible for the volunteer while the person is working on behalf of the University. The
Volunteer must also sign this form. Please retain the completed document in your department
for three years from the point at which the volunteer activity ends.
2. Address and phone number of volunteer:
3. Volunteers are required to maintain health insurance to cover their medical expenses. Please
Volunteer's emergency contact information (provide name, address, and phone number):
4. Authorized period of time for conducting the volunteer activities outlined in #5:
1. Name of Volunteer:
indicate below the name of the volunteer's health insurance company.
5. Describe the volunteer's full scope of activities to be authorized.
(Note: Also indicate any parameters or limitations which the volunteer must adhere to while
serving as a volunteer-for example, restrictions while working in research labs, etc.):
6. Does the prospective volunteer require any special accommodations by the University