ElderNetof Lower Merionand Narberth
9 S. Bryn Mawr Avenue, Bryn Mawr, PA19010
Tel: (610)-525-0706 Fax (610)-525-7106 Website: www. eldernetonline.org
Liz Hill, Volunteer Coordinator:
Volunteer Application
Date: ______
Name: ______
Address: ______
Phone: ______(Home) E-mail: ______
______(Work) May we call you at work? Yes____ No____
______(Cell) Please indicate with a * the best way to reach you.
How did you hear about us? ______
Date of birth: ______Race: ______(for statistical purposes)
Do you drive? Y____ N____ Will you drive our clients? Y____ N____Type of car/color: ______
If you are drivingas part of your volunteer service for ElderNet, we will ask for a copy of your license and proof of insurance card at the time of application and annually thereafter. Please update us if you change insurers. Thank you!
References:
1.______
Name Phone# E-mail
How does s/he know you? For how long? ______
2.______
Name Phone # E-mail
How does s/he know you? For how long?______
3.______
Name Phone # E-mail
How does s/he know you? For how long? ______
Skills you’d like to offer: ____________
Bi-lingual? ______Computer skills?____________
Your occupation & company: __________
Organizations you belong to:______
Any organizations you volunteer with: ______
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ElderNet serves a varied population. Who would you like to help?
Any_____ Elderly_____ Younger disabled adults_____ Mental health_____ Visually impaired_____
How would you like to help?
Driving to: medical appts: Locally_____ Center City_____ Gov’t officesin Norristown_____
Grocery shopping: With Clients_____ For Clients_____ Essential Errands to Bank, Pharmacy, etc_____
Telephone reassurance: A friendly call to your client each morning _____
Friendly Visits: Companion activities (visit, read to, go for walks)_____ Read mail, pay bills_____
Fill out forms_____ Go on short outings_____ Do small projects_____
Odd Jobs: Small repairs/handyman_____ Yard work_____ Shovel Snow _____ Paint _____ Help client prepare for a move_____ House Cleaning_____ Clean out a closet/cupboard_____ Laundry _____
Office volunteer: ______
Volunteering with ElderNet is very flexible!
When are you generally available? (days of week/time of day)______
Are you interested in helping…
1 x Week____ 2 xMonth____ 1 x Month____ Other______
When can you start? ______
Please note: For the safety of our clients, ElderNet must perform a criminal background check on volunteers.
There is no cost to the volunteer. We will need a copy of your legal ID for the background check.
Any former first/last names:______
I have read this form, understand the questions, and have represented my information factually.
Signature:______Date:______
For office use:
Interview ______Date & Initial ______Email/hours ______
Background: ______Date & Initial: ______Newsletter ______
D’s Lic & Ins: ______Card file ______
VolMan ______
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