Name: Date of Birth:
Address: City: State: Zip:
Home #: Work #: Email Address:
May we contact you at work? Yes No
Emergency Contact: Relationship to you: Phone #
Volunteer Services I am able to provide:
Local Transportation Snow Removal Yard Work
Long Distance Transports Friendly Visits Basic Home Repair
Telephone Reassurance Laundry Reading
Meal Preparation Light Housekeeping Respite
I prefer to work with: Males Females All
I would be available to work the following days and times:
Health Limitations (Example: “No lifting over 10 lbs.”):
References: Please provide three (3) references who are not related to you.
Name Address Phone
Do you own a vehicle? Car Truck Van
Is your vehicle insured? Yes No If yes, please provide copy of current proof of insurance.
Driver’s License #: Expiration Date: Please provide copy of Driver’s License.
Have you had any traffic citations in the last five (5) years? Yes No
Would you give us permission to run a Motor Vehicle Report? Yes No
Will you submit to a background check and fingerprinting? Yes No
Have you ever been convicted of a misdemeanor or a felony? Yes No
If yes, please state type of offense:
Interlink Volunteer Caregivers, Inc. is dependent upon a climate of mutual caring and trust between volunteers and the clients they serve. As volunteers work with clients, they observe lifestyles, belongings, and family situations; also, personal information may be shared, such as income, medical problems, and age.
In order to maintain the trust shown us by their requests for assistance, we must strive to guard the dignity and privacy of everyone we serve. Personal information about a client should not be shared with anyone.
In order to better serve the clients, an orientation is provided for all new volunteers. Bi-annual workshops/support meetings are also provided for all volunteers in order to share information, provide updates, and maintain open communication between staff and volunteers.
Interlink Volunteer Caregivers, Inc. offers excess liability and auto insurance coverage for all volunteers. Any volunteer who is providing escorted transportation for Interlink Volunteer Caregivers, Inc. will be required to provide the office with a copy of current proof of vehicle insurance and a copy of their driver’s license. (PLEASE ATTACH)
All information provided to Interlink Volunteer Caregivers, Inc. is strictly confidential.
- I understand the need for Interlink Volunteer Caregivers services in the communities it serves and that my volunteer assignment is an important commitment. I will make every effort to live up to my responsibility.
- I understand that I will be required to meet with the Executive Director for a one-on-one orientation prior to any assignments. I will also be required to attend any workshops/support meetings as scheduled, which are no more than bi-annually.
- I understand the importance of accurate record keeping for the welfare of the client and Interlink Volunteer Caregivers, Inc.
- I understand the need for confidentiality and agree to safeguard the personal information gathered about and from the client.
- I understand that while transporting a client, seatbelts are required for both the driver and the passenger(s).
- I have read and fully understand and agree to the above statements.
Volunteer Signature Date
Executive Director Signature Date