VOLUNTEER INTAKE FORM
Initial Contact Date:______________ Interview Date:_______________ Interviewer: ________________
Name: ______________________________
Address:_________________________________________________________________
Phone number: _______________________
Business/school address:________________
Congregational/agency affiliation: ___________________________________
____________________________________
____________________________________
Gender: M F Birthdate: _____________
Emergency contact: ___________________
____________________________________
Relationship: _________________________
Address:_________________________________________________________________
Phone: ______________________________
Ethnicity: ____________________________
Volunteer time available: circle
Mornings: M T W TH F
Afternoons: M T W TH F
Nights: M T W TH F
Weekends: Yes ________________ No
Languages spoken: _____________________
Setting preference: _____________________
Driver’s License: yes no
Own a Car? yes no
Length of commitment:
Willing to do “spot jobs”? yes no
Emergency contact: ___________________
____________________________________
Relationship: _________________________
Address:_________________________________________________________________
Phone: ______________________________
Life experience (paid/volunteer/other):______________________________________________
_____________________________________________________________________________
Skills, interests, hobbies: _________________________________________________________
_____________________________________________________________________________
Limitations and accommodations requested:__________________________________________
How you learned about the COA: __________________________________________________
Reason(s) for wanting to volunteer: ________________________________________________
Comments: ____________________________________________________________________
senior: Volunteer Intake rev. 09Jun01
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