Volunteers

First Name:

Last Name:

Phone (H):

Phone (W):

E-mail Address:

Address:

City:

State:

Zip Code:

In Case of Emergency

Name:

Phone:

Relation to You:

Employment

Current Employer

Name (Supervisor and/or Employer):

Position/Job Title:

Address:

City:

State:

Zip:

Dates of Employment:

Previous Employer

Name (Supervisor and/or Employer):

Position/Job Title:

Phone:

Address:

City:

State:

Zip:

Dates of Employment:

Reason for Leaving:

Community Involvement

Please list any groups, clubs or organizations you are involved with:

Are you a member of any churches (optional)? Yes No

If yes, which one (optional)?

Do you hold any certifications (i.e., CPR, Medical Certificate, Defensive Driving, First Aid)? If so, list certificates and expiration dates:

References

List 3 professional and/or personal (not including relatives) references with complete address and phone. References remain confidential.

Reference 1

Name:

Relationship:

Address:

City:

State:

Zip:

Phone:

Reference 2

Name:

Relationship:

Address:

City:

State:

Zip:

Phone:

Reference 3

Name:

Relationship:

Address:

City:

State:

Zip:

Phone:

Driving

Driver's License #:

State:

Do you have care insurance? Yes No

Insurance Company:

Policy #:

Accident Record for the Past Five Years

Please indicate the following for each accident: date, nature of accident (head-on, read-end, etc.), if you were at fault, if there were any fatalities or injuries:

Traffic Convictions (Moving Violations Only) for the Past Five Years

Traffic Conviction 1

City:

State:

Date:

Infraction:

Penalty:

Traffic Conviction 2

City:

State:

Date:

Infraction:

Penalty:

Traffic Conviction 3

City:

State:

Date:

Infraction:

Penalty:

Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No

Has any license, permit or privilege ever been suspended or revoked?
Yes No

Volunteer Experience/Information

How did you hear about The CareGivers, Inc.?

Why do you want to volunteer your time to help the elderly and disabled?

Do you have any previous volunteering experience?

Please list any hobbies, interests, or special skills you possess:

Do you speak other languages? (If so, which ones?)

How often are you willing to volunteer?

What days and times are you available or not available to volunteer?

The CareGivers, Inc. Volunteer Opportunities

Please check those that interest you:

Drive client to a doctor's office

Drive client to grocery store

Drive client to the bank

Drive client to a doctor in Boston

Drive client to a doctor in Concord

Drive client to a doctor in Lebanon

Grocery shop for a homebound person

Visit with a homebound person 2-4 times a month

Provide respite for a family caregiver

Call a homebound person for reassurance

Help with mailings

Help with phone-a-thons

Assist with fundraising

Solicit donations at grocery stores

Represent The CareGivers, Inc. at informational fairs

Calling Caring Cupboard clients

Packing Caring Cupboard

Do you have any physical limitations? Yes No

Can you assist clients who need help walking? Yes No

Can you assist clients who need a wheelchair? Yes No

Can you carry groceries for a disabled person? Yes No

Do you prefer to rotate clients or would you rather help the same person on a regular basis?

Rotate Clients Help Same Person on Regular Basis

Please type your name below to indicate that you have read and agree to the following statement:

I give The CareGivers, Inc. permission to obtain a Criminal Conviction Record and Driver Record Report. I agree to read the Caregiver Code of Ethics and abide by the policies therein. I will inform The CareGivers of any moving violations or at-fault accidents that occur during my tenure as a volunteer whether or not they occur while volunteering, and agree to maintain the minimum level of auto insurance on my vehicle. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signed:

Date: