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Please complete the form below and submit. An Interfaith Caregivers representative will contact you shortly. After submission of this form, you will also be asked to complete the Interfaith Caregivers Pledge and Reference forms.

First Name

Last Name

Nickname

Date of Birth

Street Address

Street Address Line 2

City

State

Zip code

Mobile Phone

Home Phone

COVID-19: We recommend that all seniors using our services be vaccinated for Covid-19. Have you received or are you scheduled to receive them? Please list the dates of all Covid-19 vaccinations below.

Are there any physical considerations, such as allergies, mobility, or lifting issues that could affect which assignment you can take?

Which days are you available?

Sun

Mon

Tue

Wed

Thu

Fri

Sat

What time are you generally available?

Morning

Afternoon

Evening

What are your interests as a volunteer?

Companionship (visiting a client)

Respite care (visiting a client so caregiver gets a break)

Telephone reassurance

Provide a meal on an occasional basis

Grocery shop for someone

Transportation (appointments, errands, etc.)

Volunteer in the Office

Serve on a Committee

Driver's License Number

License Expiration Date

What type of vehicle do you drive?

Sedan, 2-door

Sedan, 4-door

Crossover/ small SUV

Large SUV

Minivan

Emergency Contact Name

Relationship

Emergency Contact Phone

When Interfaith Caregivers applies for grants we are asked to provide gene information on the racial backgrounds of clients and volunteers. To facilitate getting this financial support please check as many as you feel apply to you.

American Indian or Alaska Native

Asian

Black or African American

Hispanic

Native Hawaiian/Other Pacific Islander

White

Other