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Date of Birth
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Home Phone
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*
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Email
*
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Phone
Email
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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.
Phone
This field is for validation purposes and should be left unchanged.
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