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Complete Volunteer Application
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Step
1
of 4
Last Name
*
First Name
*
Date of Birth
*
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Gender/Pronouns
Address
*
City
*
State
*
Zip
*
Home Phone
Cell Phone
Do you text?
Yes
No
Email Address
*
How Did You Hear About Us?
*
Direct mail
Advertisement
Online Search
Friend / Family
Business Colleague
Other
Other:
Are You A Veteran?
Yes
No
Next
Primary Method of Transportation to Volunteer Assignments (ie –car, bus, walk, etc)
If providing Rides, Driver’s License Number
State
Auto Insurance Company
Insurance Company Phone Number
1 - Emergency Contact Name
*
1 - Relationship
1 - Phone Number
*
2 - Emergency Contact Name
2 - Relationship
2 - Phone Number
Please list any physical limitations
*
Next
Current/Previous Occupations
*
Current/Previous Volunteer Opportunities
*
Various Skills/Talents
List Any Known Languages Other Than English
Congregation Regularly Attending (if any)
What days of the week are you available? AM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What days of the week are you available? PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Desired Amount of Hours/Frequency of Volunteering
Areas of Volunteer Interest (Check All That Apply)
*
Provide Rides
Home Chores
Shopping (w/o client)
Shopping (w/client)
Telephone Visits
In Person Visits
Office Assistance
Sending Cards, Well Wishes
Yard Work
Minor Home Repairs
Information and Referrals
Client Advocacy
Board Representative
Special Events/Fundraising
Next
Please Check Yes or No to the Following Statements:
I have been convicted of a crime
*
Yes
No
I agree to have a background check run on myself
*
Yes
No
I agree to the use of photography/video for the purposes of program promotion
*
Yes
No
I agree to serve any client assigned regardless of race, sex, creed, or national origin
*
Yes
No
I will adhere to Eastside Senior Services policies, will ensureclient confidentiality, and will hold a high standard of conduct
*
Yes
No
Driver's License/Personal ID File Upload
Click or drag a file to this area to upload.
Are You Applying to help with Transportation?
Yes
No
Insurance Card File Upload
Click or drag a file to this area to upload.
Signature
Clear Signature
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Comment
Submit