FAITH IN ACTION
Caring Hearts, Helping Hands
Faith in Action Volunteer Application
Your Name:
Street Address:
Your E-mail Address:
City:
State/Zip Code
Your Phone Number:
Church/Group
Volunteer Preferences:
Friendly Visits
Yard Work
Shopping/Errands
Transportation
Light Housework
Writing/Reading
Respite Care
Minor Home Maintenance
Telephone Reassurance
Meal Delivery
Volunteer Coordinator
Hospice Volunteer
Please list the days and times that you
would like to volunteer;
I can Volunteer:
Once a week
more than once a week
as needed
Please list your general interests, skills,
and hobbies that may assist us in
matching you with a care recipient.
Do you Smoke?
Yes
No
Are you allergic to any pets?
No
Yes
I prefer to volunteer:
Only in my congregation
Wherever needed
Do you have any other preferences for
volunteer assignments (distance from
home, gender of care receiver)?
Do you have any reservations about
volunteering with Faith in Action?
Do you have a valid driver's license?
Yes
No
Driver's License Number
Insurance Company
Policy Number
Do you have any phsyical condition that
may limit your volunteer activity?
Yes
No
If yes, please describe
Emergency Contact:
Relation:
Name:
Phone:
References (Addresses Required):
Please list three persons we may contact who are not family members. You may include employers, teachers,
religious leaders, or others whose relationship to you is more than a personal friend.
Relation:
Name:
Phone:
Address:
Name:
Phone:
Relation:
Address:
Name:
Phone:
Relation:
Address:
I understand that by submitting this application on-line, I am giving my consent for Faith in Action to contact my
references, and perform necessary background and driver's license checks.
