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 - $30,000
$31,000 - $40,000
$41,000 - $51,000
$62,000+
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
Sex
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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