Volunteer Signup
If you are interested in volunteering, complete this application online and then submit it. The Volunteer Coordinator will contact you to discuss where your interets lie and schedule you to attend a one hour orientation session.

First Name *
Middle Initial
Last Name *
Address
City
State
Zipcode
Phone
Email Address
Birthday  /  / 
Church Affiliation
Active Member?
 
EMPLOYMENT (past occupation, if retired)
Name
Address
City
State
Zipcode
Work Phone
May we call you at work?
Availability
Time Mon. Tue. Wed. Thurs. Fri. Sat. Sun.
Morning
Afternoon
Evening
Do you have any health concerns or special circumstances that would limit your volunteering? If so, explain.
Please identify the volunteer areas where you would like to assist
Respite Care Friendly Visiting
Transportation Grocery Shopping / Errands
Light Housework Handy Work / Yard Work
Office Recording of newspaper for visually impaired
Other
Please review your previous work and volunteer experiences.
Please list any special training, skills or hobbies (CPR, computer, gardening, etc.)
Do you have a valid driver’s license?
License No.
State
Insurance Co.
Policy No.
Make of Car
Color of Car
Have you ever been convicted of violation of any laws, traffic or otherwise? If so, explain.
Why would you like to become a Samaritan Caregivers volunteer?
 
EMERGENCY CONTACTS
Name
Relationship
Phone
Name
Relationship
Phone
 
REFERENCES (Please list two references who are not family)
Name
Address
City
State
Zipcode
Phone
Relationship
Name
Address
City
State
Zipcode
Phone
Relationship
 
 I give Samaritan Caregivers, Inc. permission to conduct a background check so I may provide volunteer services for the organization. I understand that this will include a check with references, a limited criminal history background check and verification that I have a valid driver’s license.
 




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