Volunteer Application

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Work Phone
Email*
Preferred Method(s) of Contact
- Phone
- Email
- Text
Emergency Contact*
Emergency Contact Phone*
Relationship to Emergency Contact*
Employment
Are you employed?*
- Yes, full time
- Yes, part time
- No
- Self-Employed
- Retired
Place of Employment*
Position/Title*
Education
Highest Level of Education*
School*
Degree/ Course of Study*
Skills & Interest
Special training, certifications, skills, and hobbies*
Groups, clubs, organizational memberships*
Please describe your prior volunteer experience (include organization names)*
Do you speak a foreign language?*
- Yes
- No
If yes, what language(s)
What experiences have you had that may prepare you to work as a volunteer serving seniors and persons with disabilities?*
What do you want to gain from this volunteer experience?*
Please check all current volunteer opportunities in which you have interest:*
- House Modification Program
- Wednesday Crew Home Maintenance/Home Repair Project
- Internship
- Community Outreach (events, fairs)
- Senior Nutrition Program
- Board Member
- Senior Medicare Patrol (SMP) One-on-One Counselor and Group Educator (Medicare fraud/waste, identify theft, senior financial exploitation education and reporting)
- Special Projects for Group
- Special Projects for Individual
- Administrative Assistant
- VASIA- Volunteer Advocate for Seniors and Incapacitated Adults
- Other (explain below)
If you selected other, please explain:
Please list all days and times you are available:*
Monday Tuesday Wednesday Thursday Friday Saturday
How did you hear about us?*
- Thrive Alliance Website
- Community Event
- Newspaper/Newsletter
- Volunteer Recruitment Website
- Volunteer Recruitment Fair
- Referred by Volunteer
- Volunteer Center
- Social Media Site
- Referred by a Friend
- School
- Church
- Employer
- Other
Background Verification
Have you ever been convicted of a crime? (If yes, please explain the nature of the crime, state in which the crime took place, and the date of conviction and disposition.)*
Conviction of a crime is not an automatic disqualification for volunteer work.
Have you ever been charged with neglect, abuse, or assault?*
- Yes
- No
Do you have any medical conditions that you think we should be aware of for your safety?*
- Yes
- No
Do you have a driver’s license?*
- Yes
- No
Has it ever been suspended or revoked?*
- Yes
- No
Do you have car insurance?*
- Yes
- No
Reference #1 Name:*
Name
Reference #1 Phone:*
Relationship to Reference #1:*
Length of Relationship to Reference #1:*
Reference #2 Name:*
Name
Reference #2 Phone:*
Relationship to Reference #2:*
Length of Relationship to Reference #2:*
Reference #3 Name:*
Name
Reference #3 Phone:*
Relationship to Reference #3:*
Length of Relationship to Reference #3:*
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age or disability.
Please read the following carefully before signing this application:*
- I certify the responses given herein are true and complete to the best of my knowledge.
Please read the following carefully before signing this application:*
- I understand that this is an application for and not a commitment or promise of a volunteer staffing opportunity.
Name
This field is for validation purposes and should be left unchanged.

Accessibility by WAH

(866) 644-6407

(866) 644-6407

Volunteer Application

Employment

Education

Skills & Interest

Background Verification

Our Policy