FOSTER GRANDPARENT PROGRAM

DeQueen-Mena Educational Cooperative

PO Box 110

Gillham, Arkansas71841

Phone: (870) 386-2251 Fax: (870) 386-7731

VOLUNTEER APPLICATION
I. PERSONAL INFORMATION

Name______

First Middle Last

Address______

Street or PO Box City County State Zip

Telephone______Race______Sex _____Marital Status______

Date of Birth______Age_____Number of People in the Household______

Social Security Number______

Name of Spouse______

Email address______

II.WORK HISTORY

Previous Occupations:______

Highest Grade Completed:______Where:______

Special Training:______

Hobbies & Skills:______

Language(s) spoken:______

References (Personal acquaintances other than relatives.)

NameAddressCity, StateTelephone

1.

2.

III. INCOME STATEMENT-
To be eligible for the stipend, you must meet certain income requirements.
SOURCE / SELF / SPOUSE / TOTAL
SOCIAL SECURITY / $ / $ / $
PENSION-RETIREMENT / $ / $ / $
SSI / $ / $ / $
VETERANS / $ / $ / $
OTHER / $ / $ / $

TOTAL HOUSEHOLD INCOME

/ $ / $ / $
OUT OF POCKET MEDICAL EXPENSES PER MONTH $______
IV. EMERGENCY AUTHORIZATION

In case of emergency due to accident or illness, requiring a doctor's attention, a Foster Grandparent representative is authorized by me to call:

Physician’s Name:______Telephone:______.

Other person to notify in case of an emergency:

Name______Relationship______

Telephone: Home______Work______

V. ACCIDENT INSURANCE BENEFICIARIES

The Foster Grandparent Program carries accident insurance with Corporate Insurance Management Company on each volunteer. Please list two beneficiaries for this policy and any accumulated earning with the right of revocation

Primary Beneficiary

Name:______Relationship______

Address:______

Secondary Beneficiary

Name:______Relationship______

Address:______

VI. TRANSPORTATION AGREEMENT

If accepted into the FGP Program, I will use the following transportation for traveling to and from my work station please check ONLY ONE):

___Private vehicle ___Walking ___Car Pool ___Other______

FOR VOLUNTEERS TO RECEIVE TRAVEL REIMBURSEMENT, THEY MUST

MAINTAIN AT LEAST LIABILITY INSURANCE COVERAGE ON THEIR AUTOMOBILE AND HAVE A CURRENT DRIVER'S LICENSE.

POLICY NUMBER:______COMPANY:______

Agent:______Expiration Date______

Driver's License #______Expiration______

VII. BACKGROUND INFORMATION

Have you ever been convicted of a felony? Yes No

VIII. PREFERENCES

What age groups would you like to work with?(mark all that apply)

_____ ages 3 – 4 (Pre-school)

_____ grades Kindergarten through the 4th grade

______Junior high kids

_____High School kids

In which town(s) are you interested in working? ______

How did you hear about the program?

___ Newspaper, TV, or Radio

___ Received flyer in mail

___ Present Foster Grandparent (if so, who ______)

___ Other (please explain) ______

If enrolled in this program, I understand that I will be required to acquire an annual physical examination at the expense of the Foster Grandparent Program. I also understand that I will be required to attend regular training sessions in preparation for my job assignment. Upon signing this application, I agree to keep liability insurance equal to minimum limits required by Arkansas. I also give my permission for the Foster Grandparent Program to release any photo of me working with assigned children to any news media. I hereby certify that the statements and designations made by me in this application are true and correct to the best of my knowledge. If enrolled I will be honest in all areas including claiming hours worked, mileage claimed, annual income, etc.

______

Applicant Signature Date FGP Project Director Date