Form Center

2. 65 Mount Hope Road Rockaway, NJ 07866
4. Department of Community Services

   Bryan Coward, Director of Recreation

6. Peter N. Tabbot, Health Officer / R.E.H.S
8. Volunteer Resume / Application

   To protect the safety and security of those we serve Rockaway Township will conduct reference and background checks for all potential volunteers. Your signature on the Authorization of Disclosure form authorizes Rockaway Township to conduct a background check to obtain information through criminal record inquiries, public records, and driving record. 

   The Authorization of Disclosure form will be completed in person. 

10. Last Name
11. First Name
12. Middle Initial
14. Street Address
16. City
17. State
18. Zip
20. Home Phone
21. Cell / Pager Number
23. Email
25. Current Employer
27. Street Address
29. City
30. State
31. Zip
33. Emergency Contact:
34. Emergency Contact Phone Number
38. Please indicate the Route you would like to deliver:

    1. Route A; Mt. Hope and White Meadow Lake
    2. Route B; Hibernia, Lake Telemark and Green Pond
    3. Either Route

    Meals on Wheels delivers hot meals to individuals along two routes in Rockaway Township. Please note these are general areas, and may change.
42. Additional Personal References We May Contact:
44. Name
45. Relationship
46. Phone
48. Name
49. Relationship
50. Phone
52. Name
53. Relationship
54. Phone
56. Signature*

    I certify that the information provided by me is true and accurate to the best of my knowledge. I understand that if any such information is willfully false, I am subject punishment. I further understand that falsification of this application and content herein may result in dismissal as a volunteer from Rockaway Township programs. I authorize Rockaway Township to investigate all statements contained in this application. I acknowledge that if I drive my own vehicle on behalf of Rockaway Township, I will always maintain in force adequate automobile insurance; and I also understand that as a volunteer driver, the limits and coverages provided by my personal automobile insurance are applicable to any accidents or incidents that involve my vehicle, including those that occur while I am serving as a volunteer driver for Rockaway Township.

    1. I Agree
57. Date
    Date
59. Date Application Was Received
    Date Application Was Received

    Date Application Was Received
60. Copy of New Jersey Driver's License

    1. Yes
    2. No
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field