Volunteer Application "*" indicates required fields Step 1 of 4 25% Name* First Last Gender* Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmail* Referred by: Please check services you'd like to offer* Friendly phone call Friendly visitor Dog walking Office Clerical Phone Coordinator Light yard work Household chores/light housecleaning Transportation: Grocery shopping for Transportation: Grocery shopping with Transportation: Medical Transportation: Other Gender willing to serve* Male Female Both Allergies? Dog Cat Smoke Other Please specify other Do you.... Accept walker Accept service pets Yes, I have a small step stool Smoke? Accept smokers? Accept portable oxygen tank? Have physical limitations? Please explain limitations* Previous volunteer experiencePrevious occupation(s)Language(s) spoken* What times are you available?* Monday/AM Monday/PM Tuesday/AM Tuesday/PM Wednesday/AM Wednesday/PM Thursday/AM Thursday/PM Friday/AM Friday/PM Saturday/AM Saturday/PM Select AllTimes of the year when you are not available Transportation InfoIf offering to transport, please enter all the information below.Vehicle make* Vehicle model* Select all that apply* 2 doors 4 doors Van or Suv Truck Emergency ContactName* Relationship* Phone*ReferencesI give permission for the following personal references to be contacted:Name* Phone*Relationship* Years known*Name* Phone*Relationship* Years known*Consent*I acknowledge that in the course of providing volunteer services, I may have access to confidential information. I understand this information should remain confidential, and if I have concerns or questions about a recipient, I will contact my Program Director. I acknowledgePublicity ReleasePublicity ReleaseI agree that Pima Council on Aging and/or the Neighbors Care Program may use the following purposes(please check each one). I understand that this publicity could include newspaper articles, television stories, a newsletter, flyers or brochures. A photograph of me Quotes from a letter/email by me A live video recording of me Quotes from an interview with me Volunteer Transportation Service OnlyDesignation of Beneficiary for Accidental Death Insurance.Name Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Neighbors Care Volunteer Application - Driver FormCar insurance provider* Policy #* Driver's license #* State issued* Expiration Date* Transportation Agreement 1*I understand I will be volunteering my services with the Eastside Neighbors Volunteer Program (Neighbors Care Program) and as such, am not acting in the capacity as an employee of ENVP, Pima Council on Aging (PCOA), or RTA. I agree to follow all policies and procedures.Transportation Agreement 2*I understand that Eastside Neighbors Volunteer Program (Neighbors Care Program), PCOA or RTA are NOT liable for any accidents or claims which might occur during my volunteer activity. I agree that my personal automobile, or other personal insurance, covers me and any recipient I am transporting in my role as volunteer. I will maintain a valid driver’s license and arrange to keep in effect auto liability insurance equal to the minimum limits required by Arizona. I agree and will provide a copy of my driver's license and insurance card.Transportation Agreement 3* I understand seat belts MUST be worn by drivers and all passengers at all times.Transportation Agreement 4*I understand that I may be eligible for reimbursement for mileage expenses through PCOA and the Regional Transportation Authority (RTA). I understand.Transportation Agreement 5* I understand that I am not to use my cell phone during any time I am driving with a recipient, EXCEPT in case of emergency.Driving RecordHave you been cited for any moving violations within the past 3 years?* No Yes Have you been cited for driving while intoxicated or for reckless driving within the past 3 years?* No Yes Volunteer Code of ConductAs a volunteer for the Eastside Neighbors Volunteer Program, Neighbors Care Program, I agree to the following guidelines for my interactions with recipients and volunteers. You must check each item* Respect - to treat others with respect, dignity, fairness, courtesy; to encourage honest, constructive, professional communication; and to be forthcoming with concerns or questions.You must check each item* Skill development - to continually explore ways to improve my skills and abilities.*You must check each item* Non-discrimination - to maintain an environment that is free from discrimination or harassment, and to appreciate and embrace the diversity in our group; respecting differences in race, color, religion, gender expression, age, culture, disability, marital status, sexual orientation and military status.*You must check each item* Confidentiality - to maintain and respect protected health and personal information given to us by our recipients and others with whom we do business. I will contact the Program Director if I have any questions or concerns about confidential information about a recipient or volunteer.*You must check each item* Conflict of interest - to disclose potential personal conflicts of interest, and refrain from accepting or soliciting, directly or indirectly for personal use, anything of economic value such as gifts, gratuities, favors, entertainment, loans or bequest.*You must check each item* Compliance - to comply with applicable statutes, and organizational policies and procedures.*You must check each item* Professionalism - to refrain from discussing my own personal problems or political or religious beliefs, and from giving personal advice to the recipient.* I will not use the recipient's phone for personal calls; I will not bring personal friends or relatives to the recipient's home; I will not consume alcohol or smoke while volunteering; I will not use the recipient's car. Signature*NameThis field is for validation purposes and should be left unchanged.
