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:                                                                                                                                                                                           


Volunteer Agreement

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