Thank you for your interest in serving others through EH
Spencer Foundation’s program FAITH IN
ACTION. When you volunteer your time
using your special abilities, interests, and talents you are helping others
maintain their independence. Please use
this sheet to tell us about yourself and your interests.
Today’s Date_________________________
Name ____________________________________ Telephone _________
Last First MI
Address___ ____________________
City__________ ___State__________ Zip_________
Email
Address______________________________________________________
Home Phone (____) _______-__________ Cell Phone (_______) _______-__________
Employer________________________________ Retired from
_____________________________________
Work Phone (_______) _______-__________
May we call you at work? £
yes £
no
Male_____ Female_____ Birth Date: _______________________
Faith
Community Affiliation__________________________________________________________
City/State________________________________________
Phone (_______) _______-__________
Emergency
Contact___________________________________ Telephone (_______) _______-__________
Address___________________________________________
Relationship to you_______________________
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When are you available to volunteer? (Check
all that apply)
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Time / Day
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Sunday
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Morning
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Afternoon
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Evening
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·
How often would you like to volunteer?
__ Once a week __ Twice a week __
as needed __ other _______________________
·
I prefer to volunteer (Check only one)
__Wherever needed __
for persons of the same faith only __
for persons in my faith community only
·
List any special considerations for your
placement (distance from home, age or gender of neighbor)
_______________________________________________________________________________________
·
If available, are you willing to do on-call jobs
with short notice? __
yes __
no
·
How were you referred to FIAQC?
__________________________________________________________
·
Please check the ways in which you are able to
help
_____ Companionship visits
_____ Respite care
_____ Light housekeeping
_____ Yard work
_____ Minor home repairs
_____ Shopping or running errands
_____ Transportation / Escort
_____ EHSF/FIA Office Assistance
_____ Photographer
_____ Prayer team
_____ FIAQC Special Events
_____ Telephone Reassurance
·
Do you have any health or physical conditions
that might limit the level of activity to perform certain tasks? £
yes £
no If yes,
describe_______________________________________________________________
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Are you a smoker? __
yes __
no
·
Do you have allergies to pets? __
yes __
no
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Are you willing to visit a smoker? __
yes __
no
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Volunteers Experience – If you have volunteered
in the past, please let us know what you have done.
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Volunteer
organization, city
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Volunteer dates
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Title/description
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May we call?
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Do you have a _____car _____truck _____van
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How far are you willing to drive? __________miles
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Do you have a valid ___IL / ___IA driver’s
license? If yes, indicate
number______________ Exp _____
If no, how will
you get to volunteer assignments? ___________________________________________
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Name of auto insurance
company______________________________City/State_________________
Policy
holder______________________________________________ Expiration
date____/____/____
Policy
number_____________________________________________
(If you drive
for FIAQC, you must have copies of your license and insurance on file at the
FIA office)
·
Have you ever been convicted of violations of
any laws, traffic or otherwise? __yes __
no
If yes, please
describe __________________________________________________________________
In accordance with the
Faith in Action National Network guidelines, EH Spencer Foundation is required
to conduct a security and driving check of all volunteers/staff. I hereby consent to the fore mentioned, also
giving my consent to contact the organizations I have volunteered for.
___________________________________________ ______________________
Signature Date
Please print and return this to EH
Spencer Foundation ~ 22621 ½ Rt. 2 & 92 ~ Port Byron, IL 61275
or Fax to 309-523-2080
Call
with questions – 309-523-3880, Toll free 877-923-3890
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