Volunteer Application for Caregiver Companion

Volunteer Application
Details about you
Name*

PrefixFirst NameLast Name
Today's Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a current student?*
Occupation or Area of Study*
In which area(s) would you like to volunteer?*
Some of our Neighbors are smokers- are you ok being around a smoker? (Note: They will never smoke with you present).*

Yes, I'm ok around a smokerNo, do not pair me with a smoker
Some of our Neighbors have pets- are you ok being around animals?*

Yes, I'm ok around all animals (dog, cat, bird, etc).I am only ok around dogsI am only ok around catsNO, do not pair me with anyone with pets
Some of our Neighbors need some help around the house. Are you comfortable with any of the below?*

Vacuuming, sweeping, dusting, etc.More extensive cleaning- kitchen, bathrooms, etc.I am not comfortable with any of the above
Please tell us some of your hobbies, likes, dislikes, interests, etc.
Do you speak any languages other than English?
If yes, please list
Do you have any volunteering experience? If yes, please describe.*
Availabilities
Select your available days*

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundaysMornings OnlyAfternoons Only
From*

Hour Minutes

AM/PM Option
To*

Hour Minutes

AM/PM Option
Additional notes about your schedule
Transportation Volunteers

Please only fill out if you are interested in providing transportation services and are 25+
Do you have a valid drivers license?
What state is it from?
Drivers license number
Insurance company
Type of vehicle (Example: Red 4 door 2015 Lexus RX 350)
Can you accommodate a walker?
Emergency Contact
Emergency contact name*
Emergency contact relation to you (example: mom, brother, roommate)*
Emergency contact phone number*
Please enter a valid phone number.
References
Reference #1 Name, relation, and phone number*
Reference #2 Name, relation, and phone number*
Please note that if we can not get ahold of your references, we may require others
Confidentiality
I know my neighbor may share personal and private information with me during my visits. I promise to keep any information I may receive from my neighbor completely confidential. (Please type your name below if you agree).*
Media Permissions
I give Caregiver Companion permission to use my photograph and/or quotes in all publications, including but not limited to: social media, press releases, marketing, etc.*

Yes, I consent to allNo, I consent to none
Background Check Authorization
Full legal name*
Previous names you may have gone by (if applicable)
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby allow Caregiver Companion to perform a check of my background, including criminal check, driving record, and personal references as appropriate, for the volunteer positions in which I have expressed an interest.
I do understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for some types of volunteer work. I understand that the information collected during this background check will be limited to that which is appropriate to determine my suitability for the particular types of volunteer work and that all such information collected during the check will be kept confidential. I hereby also extend my permission to those individuals or organizations contracted for the purpose of this background check to give their full and honest evaluation of the suitability of the described volunteer work and such other information as they deem appropriate.
I hereby allow Caregiver Companion to perform a check of my background, including criminal check, driving record, and personal references as appropriate, for the volunteer positions in which I have expressed an interest.*

Yes, I consent to allNo, I consent to none*
*Please note that if you select "No, I consent to none", your volunteer application will not be approved.
Today's Date*

MonthDayYear
Date
Please type your name below. Typing your name acts as a signature, and an agreement that the information that you provided is factual.*

First NameLast Name
Should be Empty:

Details about you

Availabilities

Transportation Volunteers

Emergency Contact

References

Please note that if we can not get ahold of your references, we may require others

Confidentiality

Media Permissions

Background Check Authorization

I hereby allow Caregiver Companion to perform a check of my background, including criminal check, driving record, and personal references as appropriate, for the volunteer positions in which I have expressed an interest.

*Please note that if you select "No, I consent to none", your volunteer application will not be approved.