Volunteer Application - Eastside Senior Services

Last Name

First Name

Date of Birth

Gender/Pronouns

Address

City

State

Zip

Home Phone

Cell Phone

If sharing your cell phone and by submitting this form, you agree to receive SMS from Eastside Senior Services. Carrier and Data rates may apply. Message frequency may vary Reply STOP at any time to end messaging or Reply Help for more information or you can say any information entered on this page will not be used to initiate SMS

Do you text?

Yes
No

Email Address

Other:

Are You A Veteran?

Yes
No

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

Current/Previous Occupations

Current/Previous Volunteer Opportunities

Various Skills/Talents

List Any Known Languages Other Than English

Congregation Regularly Attending (if any)

Desired Amount of Hours/Frequency of Volunteering

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

Signature

Clear Signature

Please use your mouse to sign