iCare Volunteer Application

I CARE, Inc. 735 Sycamore Drive, Decatur, GA 30030

Office: 404-377-2273

Email: coordinator@icareseniors.org

Volunteer Application Form

ICARE provides FREE transportation for seniors of DeKalb County to medical appointments. We have been serving fixed and low income DeKalb seniors since 1999. The FREE transportation and companionship provided to our clients makes I CARE a unique door to door service. It is solely due to a committed group of volunteer drivers that we are able to serve the seniors of DeKalb County.

Thank you for your interest in joining our team!
Full Name

First NameLast Name
MI
Middle Inital
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Zip
Phone Number
E-mail address
example@example.com
How did you hear about I CARE?
Please provide the name and phone number of two references (people not related to you):
1). Full Name
Full Name
Phone Number
Please enter a valid phone number.
2). Full Name
Full Name
Phone Number
Please enter a valid phone number.
Do you have any current or previous volunteer experience?

YesNo
Please give a brief overview of your volunteer experience:
Emergency Contact Name
Full Name
Emergency Contact Phone Number
Driver's License State of Issuance
Driver's License Expiration Date

MonthDayYear
Date
Driver's License Number
Make and Model of Vehicle
Automobile Insurance Company name
Insurance Policy #
Auto Insurance Expiration date

MonthDayYear
Date
Have you had any accidents/tickets in the last 5 years?

YesNoOther
I agree that the driver and all passengers will use seatbelts at all times. I will obey all applicable driving laws. I understand that the failure to follow these laws may result in my immediate prohibition from providing further volunteer driver services with I CARE, Inc.
Applicant signature

Clear
Date

MonthDayYear
Date
The following information will help us match your preferences with client needs:
Date you will be able to begin driving?

MonthDayYear
Date
How many rides do you wish to take per month?
If in general, there are particular days and times you are most available, you may indicate them by marking "yes" or "no" on the chart below. NOTE: If your schedule varies, and you prefer to notify us of your availability periodically, you need not complete this chart.

Availability:

	Monday	Tuesday	Wednesday	Thursday	Friday
Mornings (9am-11am)
Afternoons (12pm-3pm)
Evenings (4pm-7pm)
Unavailable

As part of my volunteer application, my signature below authorizes the above company to receive any criminal history record information pertaining to me that may be on file at any state or local criminal justice agency.
Full Name (Printed)
Date of Birth

MonthDayYear
Date
Home Address
Street Address
City/State/Zip
E.x. Decatur, GA 30030
Sex
Race
Height
e.x 5' 4
Weight
If prefer not to say put N/A
Social Security Number
Last 4 digits only (e.x. 1234)
Signature

Clear
Date

MonthDayYear
Date
I CARE Representative Signature

Clear
Date

MonthDayYear
Date
Should be Empty: