Foster Grandparent and Senior Companion Volunteer Application

145 Parsells Avenue • Rochester, New York 14609

Please Print

Name: ______

Address: ______

Phone Number: ______

Age: ______Date of birth: ______

Check One:

Married

Single

Divorced

Widowed

Can You Read and Write?

Yes

No

Highest Grade Completed: ______

Previous / Current Occupation: ______

Have you ever worked with children orfrail elders?

Yes

No

If yes, please explain: ______

How did you hear about the programs?

______

What makes you feel you would be a successful volunteer?

______

Have you ever applied for or worked for:

The Foster Grandparent Program

Yes

No

Senior Companion Program

Yes

No

If Yes, Please Explain:

______

Which program would you like to volunteer:

Foster Grandparents

Senior Companion

Name of person to contact in case of emergency: ______

Their phone number, address, and relationship to you:

______

Do you have your own means of transportation?

Yes

No

INCOME

There are: ______(Number) of people in my household dependent on the income listed.

To the best of my knowledge and belief, the following are the source and amounts of my monthly family income:

Social Security: $______SSI/SSDI: $______

Pension: $______Interest/Dividends: $______

Other: $______

Total Yearly Salary is: $______

My signature indicates the information provided is correct and falsifying of this information my result in disqualification from the program.

Signature: ______Date: ______

Foster Grandparents and Senior Companions of Monroe County

Criminal History Check Consent Form

I, ______agree to undergo the National Service Criminal History Check, which will include the following:

  • Checks of state criminal history registries for locations where I live as well as where I will serve or work
  • An FBI fingerprint check
  • A check of the National Sex Offender Public Registry

I understand that my selection into the Foster Grandparent or Senior Companion Program, is subject to check results and that I can be disqualified for any one of the following reasons:

  1. Murder conviction
  2. Required to be registered on a sex offender registry
  3. False statement in response to inquiry about criminal history
  4. Refusal to undergo the National Service Criminal History Check

I also understand that I will have an opportunity to review and challenge the results of the checks.

Name (printed): ______

Signature: ______

Date: ______