Please
fill out this form below and we will contact you today!
Personal
Information
Name
Address
Address
2
City
State
Zip
Phone
Phone
2
E-mail
Address
Occupation
Congregation
affiliation
Volunteer
Opportunities
Transportation
Senior
Day Out
Shopping/Errands
Help
in Office
Friendly
Visits
Events/Fundraisers
Yard
Work
Telephone
Reassurance
Public
Speaking
Computer
Help in Office
Computer
Help for Clients at Home
Minor
Home Repair
Other
Placement
Preference (Please check all that apply.)
Time/Day
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Morning
Afternoon
Evening
I
can volunteer
once
a week
more
than once a week
twice/month
other
(please specify)
Matching
Information
General
interests, skills, volunteer experience, languages, and
hobbies.
Answer
the next 3 questions if you plan to drive for caregivers
What
kind of vehicle do you drive? This is helpful to know
in order to make sure that you are assigned to drive people
who can get into your vehicle.
Will
anyone else be with you in the car?
We serve people who live in Northwest Austin, Cedar Park,
and Leander. Do you have any limitations on the distance
you would drive for volunteer work?
Screening
Information
Do
you have a valid driver’s license?
Yes
No
License
number
If
driving for Caregivers,
Car Insurance Company
Policy
Number
If yes, please describe
Have
you ever been convicted for violation of any laws,
traffic or otherwise?
Yes
No
If
yes, please explain
Do
you have any physical condition that may limit your
volunteer activities?
Yes
No
If
yes, please describe
Emergency
Contact
Name
Phone
Relationship
References
Please
list two persons who we may contact who are not family members.
Name
Phone
Relationship
Name
Phone
Relationship
I
confirm that all of the above information is true and correct
to the best of my knowledge. I give my consent for Far Northwest
Caregivers to contact my references. I understand that a criminal
background check will be conducted.
