Volunteer Registration Form:

Name:
Address:
City: State:   Zip code:
Phone:     Cell/Other

Emergency Contact:

Relationship:   Phone:

References: List two people that have known you for longer than one year (Excluding Relatives)

Name:  
Phone:   Relationship:

Name:  
Phone:   Relationship:

Frequency with which you wish to volunteer:
Twice Weekly    Weekly    Every Two Weeks    Longer Interval

Time Preference:
Morning   Afternoon   Evening

Length of time you wish to serve:
1 Hour   2 Hours   3 Hours   Longer Periods

Day of week preferred:        Please Select One Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Do you wish to put a time limit on you volunteer commitment:
3 Months   6 Months   1 Year   Indefinite   Other
Other Please Specify:

Can you volunteer transportation for patients? Yes   No

Do you speak a foreign language?  Yes   No
Please Specify Language:

Have you ever had a family member or friend in a nursing home?   Yes   No
Please Specify Home:

Are there any skills drawn from previous experiences you would care to use in volunteer work?
(Other Languages, Hobbies, work or volunteer experiences). Please Specify

Select each Volunteer area of interest:

  Select any that Apply Assist finding projects for residents to contribute to the community Assist Residents Arranging Flowers Assist Residents with Writing Exercises Assist with craft projects Assist with Games Assist with Group Sings Assist with Parties Assist with Planning Special Events Bible Stories Bulletin Boards Bus Rides Contact people for: Book Reviews, Current Events, Group Discussions, and Talks Copy Papers Current Event Distribute Magazines, Books, etc… Friendly Visiting 1:1 Letter Writing Make and Display Decorations Make Beds Make Patterns for Projects News Letter Pass out Food-trays Play Instruments Prepare Materials for Residents Serve Refreshments Show Films Sing Suggest New Activities to Activity Director Teach Painting Transport Residents to Church, Beauty Shop, and Events
To select multiple options, press and hold the CTRL key and select each one.

Additional Comments: