Volunteer Application User Information Name * First Last * Last Email * Date of Birth Gender Male Female Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Home Number Cell Phone Work Number Would you like to receive Text or Call Alerts? Text Alerts Call Alerts Primary Number Home Phone Cell Phone Work Phone Current Employer Employer Occupation Employer Address How did you hear about Senior Care Volunteer Network? DL Expiration Date Auto Insurance Expiration Date Auto Insurance Policy # What type of vehicle do you drive? Services you can provide: (Please check all that apply) Transportation (you must be 25 yrs. old) Newsletter Electrical Painting Plumbing Expos/Events/Parades Friendly Visit Fundraising Gutter Cleaning Home Repair (Minor) Intake Respite Care Shopping/Errands Snow Removal Yard Work Birthday (Flowers/Gifts) Deliveries Incontinence Supply Deliveries Holiday Deliveries Reception Office Help Phone Calls Office Help Mailings Office Help Special Projects Office Help Other Professional Skills/Hobbies (please list any professional skills and/or hobbies below) Your Availability (Please check all that apply) (Control Click to select more than one option) Monday Morning Afternoon Evening Tuesday Morning Afternoon Evening Wednesday Morning Afternoon Evening Thursday Morning Afternoon Evening Friday Morning Afternoon Evening Saturday Morning Afternoon Evening Sunday Morning Afternoon Evening Special Schedule Previous Volunteer Experience Yes No If yes name of Agency References Name Phone Number Address Relationship Name Phone Number Address Relationship Emergency Contact Name Phone Number Address Relationship Please specify group affiliation I Agree I hereby grant Senior Care Volunteer Network permission to interview me and/or to use my likeness in photograph(s)/video in any and all of its publications and in any and all other media, whether now known or hereafter existing, controlled by Senior Care Volunteer Network, in perpetuity, and for other use by the Organization. I will make no monetary or other claim against Senior Care Volunteer Network for use of the interview and/or the photograph(s)/video.