Volunteer Enrollment Application

Big Sky Senior Services, Inc. Senior Companion Program Volunteer Enrollment Application

Please print and complete all sections. Forms with original signatures are required for enrollment.
Name
Birth Date

MonthDayYear
Date
Age
Mailing Address
City
State
Zip
Phone
Cell Phone
Email
example@example.com
Do you have any of the following:

Visual ImpairmentHearing ImpairmentPhysical Impairment
How would you rate your general physical health?

ExcellentGoodFairPoor
Do you have access to a reliable vehicle?

YesNo
Are you able to commit to a minimum of 5 service hours per week? If so, what is your availability?

MorningsAfternoonsMondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please Note: A requirement of enrollment as an AmeriCorps Seniors Senior Companion Program Volunteer is the completion of a thorough criminal background check. Big Sky Senior Services, Inc. will conduct a check of the National Sex Offender Public Website, a state criminal repository check (in the state in which you reside and the state in which you will serve) and an FBI Fingerprint check.
Are you willing to undergo the required background checks?

YesNo
Volunteer Experience (Current, Past)
Employment Experience (Please summarize types of employment rather than listing places of employment)
Special Skills/Interests/Languages
What are your hobbies and interests?
Are there any activities you would NOT be willing to perform as part of your volunteer assignment? Examples: cooking, cleaning, shopping, transportation, etc.
Equal Employment Agency - BSSS SCP is an equal opportunity Agency. Enrollment is done without regard to race, color, national origin, gender, sexual orientation, religion, age, disability, political affiliation, marital or parental status, or military service. AmeriCorps Seniors SCP provides reasonable accommodations to the known disabilities of individuals in compliance with the Americans with Disabilities Act. For accommodation information or if you need special accommodation to complete the application process, please contact the Big Sky Senior Services Senior Companion Program at (406) 259-3111.

Return completed application to:

Senior Companion Program Big Sky Senior Services 935 Lake Elmo Dr, Ste. B Billings, MT 59105

Angela Carter Program Manager (406) 259-3111
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