Care Receiver Application - Interfaith Caregivers of Washington County

Your Information
Services
Emergency Contact
Submit

Contact Information

To qualify, you must be over 60 and a resident of Washington County.

Full Name (include middle initial)

Birthdate

Address

City

State

Zip

Gender

Male Female

Home Phone

Work Phone

Cell Phone

Accept text messages?

Yes No

Email

Best time to reach you?

Where did you hear about us?

Marital Status

Single Married Divorced Other

If Other, please explain:

Living Arrangements

Alone With Spouse Family Assisted Living Nursing Home Other

If other, please explain:

Ethnicity (optional)

White Hispanic African American Other

Is English your primary language?

Yes No

Is your gross household income at or below: 1 person < $1,396/month, 2 people < $1,888/month, or 3 < $2,184/month

Yes No

Note: Income level does not exclude you from Interfaith services. Income is to determine eligibility for services provided in partnership with our local food pantry.

Have you served in the US Military?

Yes No

Has your spouse served in the US Military?

Yes No

Have you been convicted of a crime?

Yes No

• Interfaith Caregivers of Washington Co. conducts public record checks on all applicant.
• Interfaith reserves the right to refuse service to any applicant.

Are there any firearms in your home?

Yes No

Does anyone in your home smoke?

Yes No

Are there any pets in your home?

Yes No

If yes, what are they?

Dog

Cat

Bird

Fish Tank

Other pets:

Would a volunteer of the opposite sex be acceptable?

Yes No

Mobility

Cane Walker Wheelchair Bed Bound None

Do you have difficulty getting into a van, truck or SUV?

Yes No

Do you use a portable oxygen cylinder when traveling?

Yes No

What are your current means of transportation?

I drive myself Spouse Taxi Family Friends Neighbor Other

If other, please explain:

*Are you a member of an area religious or civic organization, school or business?

Yes No

Name of religious or civic organization, school and/or business

*This question is optional, but sharing this information helps Interfaith build community relationships, thank you!

Transportation Service

Interfaith's Volunteer Transportation provides rides to healthcare, nutrition & wellness only. Healthcare is given priority. Requests require at least 10 business days advance notice.

Transportation Service

Yes, I am interested in Interfaith's Volunteer Transportation Service I would like information on other transportation options in Washington Co.

Help Corner:
A durable medical equipment short term loan program with locations in West Bend & Hartford. For a small deposit per item we loan wheelchairs, ramps, walkers, knee scooters, crutches, canes, shower chairs, commodes and much more for up to 90 days.

West Bend: 262-429-1161

Hartford: 262-525-8202

Help Corner

I am in need or durable home medical equipment. Please contact me. Please send me more information about Help Corner.

Helping Hand - Individual Volunteer Services
Service provided by individual volunteers, based on volunteer availability.

Services

Companionship Visits - a social visit, not intended for respite or supervision. Interfaith Canines - Companionship visits from a volunteer with their registered therapy dog Lawn mowing - please have a working mower available for our volunteer Snow Removal - please have a working snowblower and/or shovels available for our volunteer. Garbage "Can to Curb" - a volunteer to bring your garbage container to curb for weekly pick-up Kindness Calls - Friendly phone conversation with a volunteer caller. Grocery Shopping - Volunteer will grocery shop with me Grocery Shopping - Volunteer will grocery shop for me (form of payment must be provided)

Other Requests

Requests considered that fit within policy guidelines and volunteer availability.

Kindness Crew - Group Volunteer Services
Service provided when a volunteer group is available (ex. schools, churches, business.)
**Date of service based on a group availability.

YES, please contact me when a group is available for:

Spring/Summer Yard Clean-Up (Ex. lawn clean-up, minor trimming) Fall Yard Clean-Up (Ex. leaf raking, minor trimming) Spring Cleaning (Ex. dust, vacuum, wash floors) Fall Cleaning (Ex. dust, vacuum, wash floors) Meal Delivery (Groups prepare or purchase meals & deliver)

I have an "other request":

(Considered only if within policy guidelines & group availability)

Emergency Contact

If living with a spouse or other family member, please provide their information.

Full Name (including middle initial)

Relationship

Address

City/State/Zip

Home Phone

Cell Phone

Additional Emergency Contact

We require an additional contact whose information is different from the care receivers.

Full Name (including middle initial)

Relationship

Address

City/State/Zip

Home Phone

Cell Phone

Acknowledgment

Upon receipt of this application, our office will reach out to you with several additional questions to provide the most appropriate service.

I acknowledge the above information is correct. I also understand that this information may be shared with Interfaith staff and volunteers associated with Interfaith Caregivers of Washington County to provide safe and complete volunteer assistance. This information may also be shared to comply with federal reporting requirements.

Please type your name (Digital Signature)

Date

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