Amiva Companions — Volunteer Application
Take the first step to become a screened companion volunteer for isolated seniors in Orange County.
Your privacy matters to us. The information you share on this form is collected solely to review your volunteer application, match you with a senior, and complete the required screening (including a background check and TB clearance). Amiva will never sell or share your personal information with third parties for marketing purposes. Details are shared only with the screening providers and staff involved in processing your application, and are stored securely. By submitting this form, you consent to Amiva collecting and using your information for these purposes.
About You
Full Name
*
First Name
Last 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
2 digit month, 2 digit day, 4 digit 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?
*
Logistics & Safety
What are your hobbies or interests?
*
Do you have reliable transportation?
*
Yes
No
Reference Name
*
First Name
Middle Name
Last Name
Reference Relationship
*
Please Select
Supervisor
Coworker
Friend
Neighbor
Teacher
Mentor
Other
Reference Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency 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
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
Acknowledgment
Statement
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
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