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Seniors Volunteer Application

Personal Information

First Name:

Last Name:

Date of Birth:

MM slash DD slash YYYY

Email:

Phone #:

Emergency Contact Name:

Emergency Contact Phone #:

Required for Volunteer Drivers Only

(If you will be transporting a senior in your vehicle, please complete this section.)

Driver’s License #:

License Plate #:

Vehicle Make/Model and Year:

Will your vehicle fit a walker and/or wheelchair?

How many years of driving experience do you have?

Are there any restrictions on your driver’s license?

Have you ever had your driver’s license suspended, revoked, or refused?

Yes

No

If yes, please explain:

Name of your automobile insurance company (you will be required to provide a long form copy):

Have you been convicted of driving while intoxicated or under the influence of drugs?

Yes

No

If yes, please explain:

Have you had any traffic violations in the past 3 years?

Yes

No

If yes, please explain:

Have you had any type of motor vehicle accident in the last 3 years?

Yes

No

If yes, please explain:

Interests

Why are you interested in volunteering?

List any hobbies, skills, interests, or experiences that may be applicable:

What type of volunteer positions interest you?

Driver Support

Driver Support

Transportation to and from appointments. Volunteer will stay with the senior and help during the outing as needed and return the senior safely back to their residence.

Number – driver support

Available hours per week

Shopping Support

Shopping Support

Assist senior by escorting them on shopping trips and help with purchasing and putting away items.

Grocery Delivery Only

Grocery Delivery Only

Number – shopping support

Available hours per week

Friendly Visiting

Friendly Visiting

Phone calls or home visits with seniors.

Number – friendly visiting

Available hours per week

Caring Companionship

Caring Companionship

Accompany seniors out into the community for events, walks, appointments etc. Volunteer will help isolated and lonely seniors stay connected.

Number – friendly visiting

Available hours per week

Can you volunteer on a regular basis?

Yes

No

When are you available to start:

Do you speak any other languages?

Yes

No

Which languages:

Do you have any allergies?

Yes

No

Please list:

Volunteer History

Are you presently a volunteer?

Yes

No

Where?

How long?

Describe any previous volunteer experience:

Confirm

I affirm that the information provided on this application is true and complete and I understand if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Signature:

Date

MM slash DD slash YYYY

For questions, please email carlac@staidanssociety.ca.

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