Volunteer Application

Your Name



Birthdate (mm/dd/yyyy)

Day Phone

Night Phone

Cell Phone


Emergency Contacts


Primary Phone

Relationship: SpouseFriendFamilyOther


Primary Phone

Relationship: SpouseFriendFamilyOther

Religious Affiliation


Are you a veteran YesNo

Is your spouse a veteran YesNo

Volunteer Experience

Organization / Description of Service / Dates (From/To)

Work Experience

Company / City,State / Type of Work / Dates (From/To)

Volunteer Opportunities

Client Opportunities: Friendly VisitsFriendly Phone CallsTransportationRespite CareHousekeepingChoreMinor Home RepairYard WorkGrocery ShoppingSnow RemovalPhysical Fitness ProgramFood Distribution Program

Fundraising/Office Opportunities: Brat SalePork Chop DinnerOffice AssistancePie SocialBake & Craft SaleBoard/Committee MemberSilent AuctionTouching Tables for Seniors

When are you available?

How did you learn about the CARE program?
Community EventFriend/Family MemberLocal NewspaperMedical ProfessionalBenton CountyCommunity PresentationCARE NewsletterCARE WebsiteHeritage Home HealthOther (please explain)

List of References

(Please list 3 references)

Name / Relationship / Phone / Best Time to Contact




Volunteer Background/Publicity/Special Accomodations/Signature Agreements

I hereby give my consent for CARE to contact my references and to conduct a routine BCA background check. The information that I have provided in this application is true and correct to the best of my knowledge. YesNo
Initials: Date:

I hereby give CARE permission to use my name and photograph to promote the CARE program. This permission includes publicity, fundraising campaigns, and sharing photographs with other media for these purposes.YesNo

Do you require any special accommodation fromCARE to perform the volunteer responsibilities as outlined in the orientation material?
If YES, what special accommodation do you require?

If I am selected to participate in the CARE program, I understand and agree to adhere to the volunteer policies and procedures as presented to me by the administrators of the CARE program.