Amiva Companions — Volunteer Application
Take the first step to become a screened companion volunteer for isolated seniors in Orange County.
About You
Full Name
*
First Name
Last Name
Preferred Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City / General Area
*
Date of Birth
*
-
Month
-
Day
Year
Date
Languages Spoken
*
Cultural Background / Heritage
Availability & Interest
General Availability
*
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Can you commit to regular visits for at least 3–6 months?
*
Yes
No
Why do you want to visit isolated seniors?
*
Please describe any experience with seniors, caregiving, or spending time with your grandparents.
*
Logistics & Safety
Do you have reliable transportation?
*
Yes
No
Reference 1 Name
*
First Name
Middle Name
Last Name
Reference 1 Relationship
*
Please Select
Supervisor
Coworker
Friend
Neighbor
Teacher
Mentor
Other
Reference 1 Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 Name
*
First Name
Middle Name
Last Name
Reference 2 Relationship
*
Please Select
Supervisor
Coworker
Friend
Neighbor
Teacher
Mentor
Other
Reference 2 Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you willing to complete a background check and TB clearance?
*
Yes
No
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Background Check Consent & Disclosure
Background Check Disclosure
Authorization
*
I authorize Amiva to obtain a consumer report (background check) about me for the purpose of volunteer screening
Signature
*
Date
*
-
Month
-
Day
Year
Date
Acknowledgment
Statement
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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