SHIP Volunteer App 2025

Contact Information

Applicant name*

Address*

City / Town*

County*

State*

Zip code*

Date of Birth*

Date

Please note: If you reside outside of Maricopa County, your application will be forwarded to your local Arizona SHIP & SMP office.

Primary Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Number

Please enter a valid phone number.Format: (000) 000-0000.

Email address*

example@example.com

Best method and time to reach you

Emergency contact person name

Relationship

Primary Number

Please enter a valid phone number.Format: (000) 000-0000.

Other Number

Please enter a valid phone number.Format: (000) 000-0000.

Criminal Record Check

To ensure the safety of our clients, volunteers, and the communities we serve, applicants will be asked to consent to a criminal records check.

Applicant Information

Certain conflicts between personal interests and the interests of the SMP/SHIP program may exist and could prevent a person from serving as a volunteer. One example is that of a licensed health insurance agent. Some conflicts of interest, however, can be addressed in other ways and may not prevent someone from serving with the program. If you have a business or other personal interest that may create a conflict, please describe it here so we can discuss it fully during your interview.

YesNo

i If yes please

YesNo

i If yes please

3. Please tell us about your work experience, including paid and volunteer positions. If you are currently employed, please list your current job first. Use the remaining spaces to describe other work experiences (paid or volunteer) that relate in any way to the SMP/SHIP volunteer position. If you need additional space, please attach another sheet of paper.

Organization

CityState

PositionTitle

Type of work

Years

to

Paid EmployeeVolunteerOther

Organization

CityState

PositionTitle

Type of work

Years

to

Paid EmployeeVolunteerOther

Organization

CityState

PositionTitle

Type of work

Years

to

Paid EmployeeVolunteerOther

4 Please describe any skills or experience that would enable you to perform the duties of a volunteer

5 Do you speak any languages other than English Please list languages

YesNo

If yes, please describe

YesNo

How did you learn about the SMPSHIP program

1 Please tell us why you would like to become a volunteer

YesNo

3. Post completing training, please indicate the days and times that you are usually available.

Rows	Mon	Tue	Wed	Thur	Fri
Morning
Afternoon
Evening

Authorization and Certification

I certify that the information I provided in this application is true, complete, and accurate to the best of my knowledge. I also authorize the Area Agency on Aging / SHIP program to contact the references named below with regard to my application to become a volunteer. I also authorize the persons referenced to provide information in connection with my application, and release them from any liability in regard to it.

Signature*

Date

References

Please provide two references, including at least one professional or work reference, that are not related to you and who we may contact to ask about your qualifications (if the reference is a supervisor or co-worker, please note the organization for which she or he works

Name:

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How long known

Relationship

Organization

Name:

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How long known

Relationship

Organization

Name:

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How long known

Relationship

Organization

Please verify that you are human*

Volunteer Application