AmeriCorps Seniors - Senior Companion Program
VOLUNTEER FORM
Are you 55+? (Volunteers need to be 55 or older)
*
Yes
No
Do you live in Central Florida?
Orange
Osceola
Seminole
Income range (Used to determine eligibility since volunteers are paid)
$1 - $29,000
$30,000 - $39,000
$40,000 - $79,000
$80,000+
How many people are in your household?
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Birthdate
*
-
Month
-
Day
Year
Date
Are you able to volunteer virtually? (Must have a smartphone/tablet/computer/laptop that can connect to the internet)
*
Yes
No
Highest Grade Completed
*
Grade School
High School
GED or equivalent
College
Don't know
Languages Spoken
Previous Job(s)
Marital Status (please choose one)
*
Single
Widow(er)
Seperated
Divorced
Married
Gender
*
Male
Female
Race (please choose one)
African American
American Indian
Asian
Caucasian
Pacific Islander
Ethnicity (please choose one)
Hispanic or Latino
Not Hispanic or Latino
Are you a Veteran?
*
Yes
No
Do you have a disability or health condition that should be considered when arranging your volunteer assignment?
*
Yes
No
Do you have transportation to and from your volunteer assignment?
*
Yes
No
How did you hear about the AmeriCorps Seniors - Senior Companion Program?
National Service Criminal History Check
Placement in the Senior Companion Program is contingent upon a satisfactory background check including fingerprints.
Have you ever been convicted of a crime?
*
Yes
No
Submit
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