First Name   Middle Initial 

Last Name 

Today's Date 

Street Address 

City 

State   Zip Code 

Email Address 

Day Phone 

Evening Phone 

Employer 

Occupation 

Birth date 

Gender:  
 Male  
 Female  
 Transgender  
 Other  

Optional Information

Ethnic Background:
 Hispanic
 African American/ Black
 Asian
 Pacific Islander/ Hawaiian
 Native American
 Caucasian/ White
Other: 

Languages Spoken:
 English
 Spanish
 French
 Russian
 Chinese
Other: 

Religious Affiliation:
 Buddhist
 Christian
 Hindu
 Jewish
 Muslim
 None
Other: 

How did you hear about Elderfriends?
 Friend
 Group/ Club
 Craigslist
 Volunteer Match
 United Way
 Flyer/ Brochure
 Television/ Radio
 Newspaper
 School
Other: 

Questions

Why do you want to volunteer for ElderFriends?


Previous volunteer experience (last five years):

VOLUNTEER AVAILABILITY:

When are you available to volunteer?
 Weekdays
 Weeknights
 Weekends
 Holidays

Do you have a car?
 Yes
 No

VOLUNTEER INTERESTS:

One on One visits:
 Regular home visits with an isolated elderly person two-three times a month
 Assistance with on-call tasks (shopping, errands, transportation)

Holiday Program, Special Events, Fundraising, Publicity:
 Holiday meal deliveries
 Preparing holiday packages
 Helping coordinate social events
 Accompanying elders to ElderFriends social events
 Fundraising
 Asking for/picking up in-kind donations
 Web design/web maintenance
 Database design/database maintenance
 Publicizing ElderFriends at community events by staffing a booth, handing out brochures and explaining what the program does to prospective participants