VOLUNTEER APPLICATION

NAME: Age:

ADDRESS:

CITY: ZIP CODE:

TELEPHONE DAYTIME:

EVENING: CELL# email :

OCCUPATION:

PREVIOUS VOLUNTEER EXPERIENCE:

INTEREST/ HOBBIES:

LANGUAGES SPOKEN:

SPECIAL SKILLS

ARE THERE ANY HEALTH LIMITATIONS OR CONCERNS THAT WE SHOULD BE TAKING INTO CONSIDERATION?

DO YOU HAVE A VALID NYS DRIVERS LICENSE?

License Number:

Please attach or send copy of license for file!

AVAILABILITY : DAY OF THE WEEK:

TIME OF DAY:

WHAT SERVICES WOULD YOU BE INETERSTED IN HELPING WITH?

( ) FRIENDLY VISITS ( ) TELEPHONE REASSURANCE ( ) SHOPPING

( ) TRANSPORTATION / ESCORT ( ) MEALS ( ) NURSING HOME VISITS

OTHER:

HOW DID YOU HEAR ABOUT THE ST. COLUMBA HEALTH MINISTRY?

IS THERE ANYTHING THAT YOU WOULD LIKE TO SEE PROVIDED THAT WE DIDN’T MENTION ABOVE?

I UNDERSTAND THAT THIS IS A VOLUNTEER ORGANIZATION THAT OPERATES UNDER THE DIRECTION OF ST. COLUMBA CHURCH AND AGREE TO THE GUIDELINES THAT HAVE BEEN ESTABLISHED TO MAINTAIN A SAFE ENVIRONMENT FOR EVERYONE, VOLUNTEER AND RECIPIENTS .

SIGNED________________________________________________ DATE ________________

HEALTH MINISTRY

REPRESENTATIVE SIGNATURE____________________________DATE ________________