RH Package Delivery and 9/11 Registration Form

DOROT Rosh Hashanah Package Delivery & 9/11 National Day of Service and Remembrance Registration Form
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone # *
Secondary Phone #
I will pick up the package at DOROT, 171 West 85th Street (off Amsterdam Avenue) on the following day and time and deliver it to an older adult who lives between West 60th Street – West 125th Street.
Package Pick Up Appointments *
I have delivered a package/meal to a DOROT senior in the past. *

Yes No
Are you a student? *

High School College No
I am between the ages of 18-64? (Due to COVID-19 health concerns, this program is only for volunteers ages 18 - 64) *

Yes
Please note that a government issued photo ID is required for all volunteers.
For contactless verification of your identity, upload a photo of the front of your government issued photo ID, such as a U.S. driver’s license or state ID or passport. Please remember to have your ID with you when you come to DOROT. *

Browse Files

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If you do not want to upload a picture of your government issued photo ID you can provide the ID number from your U.S. driver's license or state ID or passport in the textbox below. Please remember to have your ID with you when you come to DOROT.
ID Number from government issued photo ID
Type of ID *

Driver's License Passport
Driver's License State
Date of issue *

Month Day Year
Date
In order to protect the health and safety of our older adults, on the day of the program you will be asked following questions about your exposure to COVID-19. Be on the lookout for an e-mail from DOROT on the morning of your pick up and respond to it prior to volunteering.
- Have you experienced COVID-19 symptoms in the past 14 days? You can review the symptoms here: https://forward.ny.gov/protect-yourself-and-your-family-coronavirus-covid-19
- Have you had a positive COVID-19 test in the past 14 days?:
- Have you had close contact with confirmed or suspected COVID-19 cases in the past 14 days?
If you answer Yes to any of the questions above, we will ask that you not participate in this event.
Have you, since attaining the age of 18, been convicted of a criminal offense? *

Yes No
DOROT's Terms of Service

DOROT prides itself on providing quality programs and our efforts to ensure the safety and well-being of volunteers and older adults. As a DOROT volunteer, I accept and will adhere to the following standards of behavior when engaged in volunteer activities. I understand that DOROT may terminate my volunteer engagement at any time for any reason including failure to follow these guidelines.
- I will participate in required training programs, follow all rules and use the recommended policies and procedures;
- I will adhere to all local, State and Federal laws and behave with the highest level of professionalism and integrity in all of my interactions with clients, staff and other volunteers;
- I will preserve the confidentiality of information about program participants that has been entrusted to me;
- I will not use DOROT volunteer status for personal, business or financial gain.
I agree to DOROT's Terms of Service for volunteers. *

Yes
Date

Month Day Year
Date
Enter your initials *
Please check your responses carefully for accuracy. You will not be able to revise this form after submission.
Should be Empty:

DOROT Rosh Hashanah Package Delivery & 9/11 National Day of Service and Remembrance Registration Form