Volunteer Application (Fillable)

Senior Budget Help Volunteer Application
Date

MonthDayYear
Date
Name
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip CodeCounty
DOB
Are you over the age of 55?

YesNo
Gender
Pronouns
Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email Address
example@example.com
Do you have transportation?

YesNo
Are you presently employed?

YesNo
If yes, check one:

Part-timeFull-time

Employment History

Rows	Company	Position	Skills	Years
X
X
X
X

Volunteer History

Rows	Company	Position	Skills	Years
X
X
X
X

Special skills, interests, hobbies:
List any accommodations that you require in order to successfully perform volunteer activities:
Foreign languages spoken - please list if applicable:
Ethnicity:

White (non-Hispanic)Black (non-Hispanic)Hispanic/latinoAsian/Pacific IslanderAmerican Indian/Alaska NativeOther
Have you served in the military?

YesNo
If yes, please list Branch:

Emergency Contact:
Name

First NameLast Name
Relationship
Address

Address

Street Address Line 2

CityState / Province

Zip
Phone: Home/Cell
Work
References:

Provide the name, phone number, email, and address (if known) of three non-family members who can attest your ability to volunteer.
Name

First NameLast Name
Email
example@example.com
Phone
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Name

First NameLast Name
Email
example@example.com
Phone
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Name

First NameLast Name
Email
example@example.com
Phone
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
License
Do you have a valid driver's license?

YesNo
If yes, please fill in all information below:
State of Issue
Driver’s license number
Expiration date

MonthDayYear
Date
We will submit your license for DMV LENS Program review and reporting (validity, violations Your signature indicates your acceptance of this.
Applicant Signature
Date

MonthDayYear
Date

Background Check Consent form
I hereby allow CELJ to perform a check of my background including criminal record, driving record, and personal references.

The purpose of this form is to verify that the applicant understands and consents to the criminal history record check process completed by CELJ.
Name

First NameMiddle NameLast Name
If you have ever been known by another name, please list the name(s):

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for volunteer activities and that all such information collected during the check will be kept confidential. By signing this consent form, I certify that the information given by me is true, accurate and complete. I am acknowledging that I understand CELJ’s policy on criminal background checks, and I hereby give my consent for CELJ to obtain such information. I release from all liability anyone supplying such information and I also release CELJ from all liability that might result from making an investigation.

I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability for the described volunteer work and other such information, as them deem appropriate.
Applicant Signature
Date

MonthDayYear
Date
FOR OFFICE USE ONLY
Background check performed on
Staff Signature

FINANCIAL MANAGEMENT ADDENDUM
Name

First NameLast Name
Date

MonthDayYear
Date
List memberships in civic/fraternal/church/professional or other organizations:
Do you have experience working with older adults?

YesNo
If yes, please describe:
Describe your financial management experience & special skills:
Write a brief statement of why you want to be a financial manager for an older adult?
Can you volunteer 4 hours a month?

YesNo
Can you attend an hour & 1/2 training sessions? (Day/Evening).

YesNo
Are you available to attend a monthly hour & 1/2 meeting for additional training?

YesNo
Volunteer area preference:
COMMITMENT:

This program offers confidential budgeting & bill paying assistance to help individuals manage their money, improve their finances and maintain their independence in the community. As a trained volunteer, you may work with individuals one-on-one creating and maintaining a budget, basic money management, credit, car loans and homeownership

By completing this application, you agree to attend:
- 1.5 hours training session
- 1.5 hours monthly training
- 1.5 hours visits with an older adult
Volunteer Applicant Signature:
Date

MonthDayYear
Date
Should be Empty:

Senior Budget Help Volunteer Application