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SeniorAge Volunteer Application
1
SeniorAge Volunteer Application
Thank you for your interest in serving with us as we fulfill our mission.
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2
Full Name
(First Middle Last)
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3
Date of Application
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Date
Month
Day
Year
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4
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Phone Number
Please enter a valid phone number.
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6
Email
example@example.com
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7
Date of Birth
-
Date
Month
Day
Year
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8
Sex
Please Select
Male
Female
Other
Please Select
Please Select
Male
Female
Other
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9
Race
Please Select
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander.
Please Select
Please Select
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander.
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10
SSN#
(Format: 555-55-5555)
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11
Senior Center
What desired location?
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12
Volunteer Position Sought:
Kitchen Help
Janitorial / Maintenance
Health / Wellness
IT Assistance
Tax Counseling
Patient Companion
Desk Volunteer
Respite Care
Marketing
Arts /Crafts / Music
Activities / Programs
Hospitality
Secret Shopper
Telephone Reassurance
Medicare Counseling
Meal Delivery
Other
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13
Days of Availability:
AM
PM
Both
Monday
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Tuesday
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Wednesday
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Thursday
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Friday
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Monday
Tuesday
Wednesday
Thursday
Friday
AM
Row 0, Column 0
PM
Row 0, Column 1
Both
Row 0, Column 2
AM
Row 1, Column 0
PM
Row 1, Column 1
Both
Row 1, Column 2
AM
Row 2, Column 0
PM
Row 2, Column 1
Both
Row 2, Column 2
AM
Row 3, Column 0
PM
Row 3, Column 1
Both
Row 3, Column 2
AM
Row 4, Column 0
PM
Row 4, Column 1
Both
Row 4, Column 2
1
of 5
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14
What other volunteer or background experience do you have?
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15
Have you ever been convicted of a crime?
YES
NO
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16
Please explain the nature of the crime and the date of the conviction and disposition.
Conviction of a crime is not an automatic disqualification for volunteer service.
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17
References (1 of 3)
Please list three people who know you well and can attest to your character, skills, and reliability.
Name/Organization
Relationship to you
Length of relationship (in years)
Phone number
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18
References (2 of 3)
Please list three people who know you well and can attest to your character, skills, and reliability.
Name/Organization
Relationship to you
Length of relationship (in years)
Phone number
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19
References (3 of 3)
Please list three people who know you well and can attest to your character, skills, and reliability.
Name/Organization
Relationship to you
Length of relationship (in years)
Phone number
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20
SeniorAge Confidentiality Policy and Volunteer Handbook
*
This field is required.
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21
Please read the following carefully before signing this application:
I understand that this is an application for and not a promise of volunteer opportunity. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would unfavorably affect my application for a volunteer position. I understand that misrepresentations or omissions may be cause for my immediate denial as an applicant for a volunteer position with SeniorAge or my termination as a volunteer and I certify the information given herein is true and complete. I authorize my name to be checked against the Employee Disqualification List. I understand that false information given or found on the EDL can result in my discharge.
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