Name 

Date 

Email Address 

Street Address 

City 

State 

Zip Code 

Day Telephone 

Evening Telephone 

Employer 

Occupation 

Birthdate 

Optional Information

Gender:
 Male
 Female
 Transgender
 Other

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

Languages Spoken:
 English
 Spanish
 French
 Russian
 Hebrew
 Chinese
Other: 

Religious Affiliation:
 Christian
 Buddhist
 Hindu
 Jewish
 Muslim
 None
Other: 

How did you hear about Elderfriends?
 Friend
 Group/ Club
 Volunteer Center
 Flyer
 Television
 Newspaper
 Radio
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:

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

Holiday Program and Special Events:
 Holiday visits
 Meal deliveries
 Preparing holiday packages
 Getting food and other supplies donated
 Picking up materials donated by others
 Helping with recreational outings

Administration
 Word-processing or data entry
 Bulk mailings
 Calling volunteers or elderly

Other Volunteer Interests:

References (other than relatives)

Please fill out this section ONLY if you plan to become a Visiting Volunteer

Name 

Relationship 

Day Telephone 

Evening Telephone 

Number of years known 

Employer Contact 

Phone 


Name 

Relationship 

Day Telephone 

Evening Telephone 

Number of years known 

Employer Contact 

Phone