Faith in Action: Elder Outreach

Volunteer Application

________________________________Please print__________________________________

Personal information:

Title ________ First Name _________________________ Last Name _____________________________ Age ________________

(Mr. Mrs. Ms…)

Address _______________________________________ Email _______________________________________________________

City __________________________________________ State ________ Zip ____________________

Home Phone: _______________________ ext. _________ Work Phone: __________________________________ ext. _________

Cell Phone: _________________________Fax: ________________________ Birth Date: _____________________ Sex: ______

How long have you lived at your current address? ___________________________ Ethnicity ______________________________

Congregation (optional) ________________________________________________________________________________________

Occupation ____________________________________ Name of Employer (optional)_____________________________________

How did you become interested? _______________________________________ Are you an AARP member? _____ yes _____no

Volunteer Options: Please check areas in which you are interested in helping.

1 ____ Friendly Visiting	8 _____ Light Maintenance/ Home Repairs
2 ____ Transportation	9 _____ Meal Preparation
3 ____ Respite Care	10 ____ Meal Delivery
4 ____ Shopping/Groceries	11 ____ Light Housekeeping
5 ____ Reassurance Phone Calls	12 ____ Pet Care
6 ____ Paperwork/Administration	13 ____ Other (please specify below)
7 ____ Plant Care

If Other, please specify _______________________________________________________________________________________

Placement Preference: Please check all that apply

Availability

Morning (M)

Afternoon (A)

Evening (E)

Are you willing to do spot jobs at your convenience? _____ yes ______ no

I can volunteer: Once a week ____ More than once a week ____ As needed ____ Other ____

Matching information:

General interests, skills, volunteer experience, languages, hobbies: ______________________________________________________

____________________________________________________________________________________________________________

Do you smoke? ___ yes ____ no Are you allergic to pets? ___ yes ____ no

I prefer to volunteer: ____ wherever needed ____ through my congregation only

If volunteering for transportation, how far are you willing to drive? _______ miles

Do you have transportation to get to assignments? ____ yes ____ no If no, how will you get there? _________________________

List any specific considerations for you placement (distance from home, preference for age or gender of care receiver)? ____________________________________________________________________________________________________________

What reservations, if any, do you have about volunteering with Faith in Action? ____________________________________________________________________________________________________________

Screening Information:

Do you have a valid driver’s license? _____ yes _____ no

License number _________________________ Expiration date _______/_______/______

Insurance Company _____________________________ Policy number __________________ Expiration date _____/_____/_____

Have you ever been convicted for violation of any laws, traffic or otherwise? ____ yes ____ no

If yes, Please explain ___________________________________________________________________________________

List all states in which you have lived in the past 5 years: _____________________________________________________________

Do you have any physical condition that may limit your volunteer activities? ____ yes ____ no

If yes, please explain: __________________________________________________________________________________

Emergency contact:

Name _________________________________ Home Phone _______________________ Work Phone _____________________

Relationship: ___________________________________

References:

Please list three persons we may contact who are not family members. You may include employers, teachers, religious leaders, or others whose relationship to you is more than a personal friend.

Name ______________________ Phone ______________________ Relationship ________________________________________

Address ____________________________________________________________________________________________________

Name ______________________ Phone ______________________ Relationship ________________________________________

Address ____________________________________________________________________________________________________

Name ______________________ Phone ______________________ Relationship ________________________________________

Address ____________________________________________________________________________________________________

I hereby acknowledge that the information given in this application is confidential and for the use of Faith in Action. I give my consent to contact my references, to contact my employers, past and present, and to conduct a routine police check.

Signature of Volunteer ________________________________________ Date _____/_____/______

Please print out this form, complete it, and mail it to:

Faith in Action: Elder Outreach

1530 Nicholasville Rd.

Lexington, KY 40503

Thank you!

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