• Your Information
  • Services
  • Emergency Contact
  • Submit

Contact Information

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

Gender

Accept text messages?

Marital Status

Living Arrangements

Ethnicity (optional)

Is English your primary language?

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

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?

Has your spouse served in the US Military?

Have you been convicted of a crime?

• 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?

Does anyone in your home smoke?

Are there any pets in your home?

If yes, what are they?

Would a volunteer of the opposite sex be acceptable?

Mobility

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

Do you use a portable oxygen cylinder when traveling?

What are your current means of transportation?

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

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

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

Services

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:

(Considered only if within policy guidelines & group availability)

Emergency Contact

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

Additional Emergency Contact

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

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.