Volunteer Application

Contact Information

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone (cell):*

Phone (home or work)

Email*

Emergency Contact Name*

Emergency Phone Number*

General Questions

How did you hear about us?*

What kind of work are you in? If you are a student, what do you study?*

In a few sentences, describe your motivation for wanting to visit the elderly.*

In a few sentences, tell us about your likes and dislikes, or any special skills or talents, such as music, languages, etc. This can be helpful to us in matching you up with a person with similar interests.*

What days of the week and times are generally best for you to visit the nursing home? (Note: Most of our volunteers join one of our volunteer groups which meet at set days and times; more information about that will be shared in response to your application)*

What past experience do you have with volunteering, especially volunteering in health care situations and/or with people who are elderly or disabled? Do you have any other past experience that you think would be relevant to this sort of volunteering?*

References

Please provide two character references below. At least one of these should be an authority figure -- i.e. current/former employer, teacher, pastor/minister, etc. Neither should be a family member.

Reference 1 Full Name*

Reference 1 Phone*

How do you know this person?*

Reference 2 Full Name*

Reference 2 Phone*

How do you know this person?*