Volunteer Application

Atwater Area Help for Seniors

PO Box 64

Atwater, MN 5620

320-974-8737

Rev.: 11/2014

Name- Last First Middle

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Home Phone

Cell Phone:

Address – Physical Mailing Town State

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Birth date

E-mail address______

Occupation: (past or present)______Retired

How would you prefer to be contacted? ___Phone, ___e-mail, ___mailed letter ___other(please list) ______

What is the best time to contact you?______

Volunteer Activities (Check all you will help with)

___Home visit (___friendly visit, ___read books to client, ___ play cards [kind?______], ____board games

___Drive clients (___in town, ___out of town Ex. St. Cloud, Twin Cities; ___to church; ___ for outing;)

___Chores (Circle: grocery shop, dust, vacuum, mop floors, laundry, sew/mend, garden, lawn care, windows, other:______)

___Pretty Nail Clinic (2nd Wed. of month 1 – 3 pm)

___Bingo (1st and 3rd Mon. of month 1:00)

___Deliver meals (__one day a week on ______; ___call as needed)

___Help at LAHBNP sponsored events (work, donate items needed, set up/take down)

___Handyman Projects (

___Office help (mailing, phone calls, filing, etc.)

___Respite care (relieving family caregiver 3 –4 hours)

___Telephone Homebound Seniors

___Train/lead Bone Builders or other exercise class (List______)

___ Board Member

___Packing/unpacking for a move

Past volunteer experience/training working with senior citizens:

______

Please list any special skills, hobbies, and interests that could help in matching you with seniors: __computer help, __ card games, __scrapbooks, __foreign/sign language

___ Other:______

Do you have any physical limitations that will limit your volunteer activities? Yes No (Ex. Unable to support elders walking, entering/exiting vehicle) Please list if yes: ______

Can you lift a wheelchair? Yes NoCould you push a wheelchair? Yes No

Are you willing to visit a smoker? Yes No Do you have problems with pets: Yes No

Do you have any allergies we should be aware of: __ Yes No List if yes:

Please list references (Not a relative):

Name______Relationship:______

Address______Day phone______

Name______Relationship:______

Address______Day phone______

If you will provide transportation, please complete the following:

Driver’s License #______Date of Expiration:______

Automobile Insurance Co. ______Car ___ Van ___ Color______

Automobile Insurance Policy Number______Car License #______

How did you hear about our program?

Sign below, read, sign and return the following pages: The confidentiality Agreement and the Volunteer Agreement.

I give permission for the Atwater Area Living At Home Block Nurse Program to check the references listed above, complete a background check, and confirm insurance coverage:

Emergency contact:______Phone______

I volunteer my services and understand that I am not an employee of the program.

Signature______Date______

Thank you for taking time to complete this information. Please return completed forms to: Atwater Help for Seniors office at 126 N. 4th St., or PO Box 64, Atwater, MN 56209.

------OFFICE Use Only------

Date received:______Date interviewed______

Background check______References checked______

Forms signed and received: Vol. agreement______

Conf. Agreement ______

Orientation ______

License current______Insured for transportation ______

Nov., 2014