Volunteer Application Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneCell Phone*Work PhoneEmail* Preferred Method(s) of Contact Phone Email Text Emergency Contact*Emergency Contact Phone*Relationship to Emergency Contact*EmploymentAre you employed?*Yes, full timeYes, part timeNoSelf-EmployedRetiredPlace of Employment*Position/Title*EducationHighest Level of Education*School*Degree/ Course of Study*Skills & InterestSpecial training, certifications, skills, and hobbies*Groups, clubs, organizational memberships*Please describe your prior volunteer experience (include organization names)*Do you speak a foreign language?*YesNoIf 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:*MondayTuesdayWednesdayThursdayFridaySaturdayHow 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 VerificationHave 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 PolicyIt 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.