Volunteer Application Your Name Birthdate (mm/dd/yyyy) Address City/State/Zip Day Phone Night Phone Cell Phone Email Emergency Contacts Name Primary Phone Relationship: SpouseFriendFamilyOther Name Primary Phone Relationship: SpouseFriendFamilyOther Are you a veteran YesNo Is your spouse a veteran YesNo Religious Affiliation Congregation Volunteer Experience Organization Description of Service Dates (from/to) Work Experience Company, city, State Type of Work Dates (from/to) Volunteer Opportunities(Please check all areas of interest) Provide Services to Clients: Transportation/RidesYardworkRespite CareHealth & Safety EducationMinor Home Repair/ModificationHomemaking/ChoresFriendly VisitingFood ProgramsPhysical Fitness ProgramsGrocery ShoppingFriendly Phone CallsArt Classes Fundraising/Office/Board Opportunities: Pork Chop DinnerSilent AuctionFoley Fun DaysBrat SaleBake SaleQuilt Raffle SalesBoutiqueTouching Tables for SeniorsEvent Booth (various expos)Office AssistanceFundraising CommitteeCommunications CommitteeBoard of DirectorsOther As a CARE volunteer, you will set your own schedule and provide services according to your passions and interests as often as you choose. How did you learn about the CARE program? CARE websiteCARE Facebook pageCARE Connections newsletterCARE Community PresentationFriend/Family MemberLocal newspaperCommunity EventMedical ProfessionalBenton CountyOther List of References (Please list 3 references) Name / Relationship / Phone / Best Time to Contact 1. 2. 3. Volunteer Background/Publicity/Special Accomodations/Signature Agreements I hereby authorize CARE - Community Action Respecting Elders to contact my references and to conduct a routine BCA background check. The information that I have provided in this application is true and correct to the best of my knowledge. YesNo Initials: Date: I hereby give CARE - Community Action Respecting Elders permission to use my name and photograph to promote the CARE program. This permission includes publicity, fundraising campaigns, and sharing photographs with other media for these purposes.YesNo Do you require any special accommodation from CARE - Community Action Respecting Elders to perform the volunteer responsibilities as outlined in the orientation material?YesNo If YES, what special accommodation do you require? If I am selected to participate in the CARE program, I understand and agree to adhere to the volunteer policies and procedures as presented to me by the administrators of the CARE - Community Action Respecting Elders. Siganture: Date:
