Contact Information
Full Name (include middle initial)
Address
City
State
Zip
Cell or preferred phone
Accept Text Messages?
Best time to reach you?
Gender
Birthdate
Are you age 55 or over?
If YES, we will tell you about the benefits of being an AmeriCorps Senior volunteer!
Volunteer Experience
Are you volunteering with a group?
If YES, name of group
How did you hear about Interfaith Caregivers?
Previous volunteer experience (who was it with/type of activity/what did you enjoy the most?)
Other information about YOU that you would like to share - education, skills, special interests, hobbies, 2nd language, etc. (This will help us match you to volunteer opportunities!)
Please share your current work experience, who it is with and/or work history you would like us to know about. (This will help us match you to volunteer opportunities!)
Do you have physical conditions/limitations that we should know about?
Do you smoke?
I would prefer volunteer opportunities with a
Are you a military veteran?
If YES, which branch did you serve?
Any allergies we should know about?
If YES, please explain:
If you volunteer in a senior's home, would you prefer:
Emergency Contact
Full Name
Relationship
Address
City
State
Zip
Home Phone
Cell Phone
Interfaith Volunteers
Driver's License #
State Issued
Expiration Date
Will you be using your personal vehicle?
Auto Insurance Company
If you have insurance questions, these will be covered at your volunteer orientation.
Policy No.
Policy Expiration Date
Vehicle Make
Model
Year
License Plate #
State
Number of passenger seats
Do you have any driving restrictions?
How many miles are you willing to travel?
Travel outside Washington County?
If using more than one personal vehicle, please list the additional vehicle's information below:
Additional Vehicles
Volunteer Opportunties
Please check all that apply or if you are interested in learning more!
Volunteer Driver
Rides to critical services like doctor appointments, pharmacy, exercise, grocery store & food pantry.
Volunteer Driver
Helping Hand Volunteer
I am interested in these individual "helping hand" opportunities.
Helping Hand Opportunities
Specify home repair/project
Kindness Crews
I am interested in being part of a "Kindness Crew" group volunteer opportunity, call me when group opportunities become available for:
Group Opportunities
H.e.l.p. Corner
Opportunities at our health equipment lending program: customer assistance at the help Corner store in West Bend or Hartford, equipment repair & maintenance, warehouse, data entry, community awareness!
I am interested in volunteering at h.e.l.p. Corner in:
Other Volunteer Opportunities
I am interested in:
Days & Times
Please list the start/end times you may typically be available to volunteer for each day:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please indicate how frequently you may be available to volunteer:
Other
May we contact you to fill in for last minute requests? (ex. A driver is ill and cannot fulfill a ride obligation)
Optional
I am a member of a religious and/or civic organization
Name of religious and/or civic organization
I have a connection to the following school and/or business
Anything else to share that may help Interfaith build or improve our community relationships?
Background Information Disclosure
Please answer the following questions as completely and accurately as possible. Answering Affirmatively to any questions will not necessarily bar you from volunteering with Interfaith Caregivers of Washington County. However, failure to comply with these requirements, or providing false information, will likely result in denial or termination of volunteer activities.
Full Name (first, middle and last)
Any other names by which you have been known (including maiden name):
Your Birthdate
Gender
Do you have criminal charges pending against you or were you ever convicted of any crime (not including traffic violations) anywhere, including federal, state, local, military and tribal courts?
If yes, list each crime, when it occurred or the date of conviction and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgement of conviction, a copy of the criminal compliant, or any other relevant court or police documents.
Criminal Charges
Has any government regulatory agency (other than the police) ever found that you abused or neglected any person or client?
If yes, explain, including when and where it happened.
Has any government regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client?
Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?
Have you resided outside of Wisconsin in the last three years?
If yes, list each state and the dates that you lived there.
Volunteer Agreement
Thank you for your application to volunteer with Interfaith Caregivers of Washington County, Wisconsin.
Please read and agree to the following:
1) Please note that, if your application is accepted, you will be a volunteer and not an employee of Interfaith.
2) Criminal background checks may be conducted on volunteers. I authorize Interfaith to conduct such a check. All information collected during the check will be kept confidential.
3) I authorize the release of information to Interfaith related to my potential volunteer responsibilities and I release all parties from any liability resulting from the release of such information.
4) CONFIDENTIALITY: It is imperative that ALL information regarding an Interfaith service receiver be treated with the utmost confidence and such information may only be released to anyone (including family members) with proper authorization. These restrictions include all types of communication: verbal, written and electronic, including social media.
5) I agree to abide by all Interfaith policies and procedures during my participation as an Interfaith volunteer. Participation as an Interfaith volunteer may be terminated at any time due to failure to comply with Interfaith policies and procedures.
6) I release Interfaith, its employees, agents, volunteers, donors and sponsors from any and all claims resulting from my participation as a volunteer with Interfaith.
