Volunteer Application Form

Date of Birth:

Name

First

Last

Email

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Preferred Contact Method:

Home Phone
Cell Phone
Email

Best Time to Contact You:

Service Areas (please select any areas which best fit services you would prefer to do):

Volunteering Opportunities—(As a volunteer, you are never assigned to a member request. No one will call you asking you to take a request. We have a password protected page on our website where only volunteers have access. Each week, we post our member requests on that page with the date and time of the request. Our volunteers check the list, if there is a request that meets your available time, you can call our volunteer coordinator and let her know you will take that request. You then call our member the day before their request to let them know what time you will pick them up. You pick and choose what you want to do. If it’s your first time, you may want to ride along with one of our volunteers as they fill a member request.)

Previous volunteer experience:

References (please list three professional/personal references, including name, phone number, and your relationship to them):

I give permission for Made to Stay to perform a criminal background check and a driving history record check if deemed necessary:

Yes
No

If you are willing to provide transportation, we will need a copy of your driver’s license and your automobile insurance showing liability coverage and coverage for any passengers.

I give permission to use my name and photo in ads, brochures, the website and any other publications of Made to Stay:

Yes
No

Made To Stay

Supporting Seniors To Stay In Their Homes

Volunteer Application Form