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Home Care / Meals on Wheels / Meals on Wheels Volunteer Form


Meals on Wheels Volunteer Form

Meals On Wheels Service Area

One county service area map

To protect the safety and security of those we serve UR Medicine Home Care will conduct reference and background checks for all potential volunteers. Your signature on the Authorization of Disclosure form authorizes UR Medicine Home Care to conduct a background check to obtain information through criminal record inquiries, public records, and driving record.

If you would like to volunteer for Meals On Wheels, please fill out the form below.

Your Information

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Preferred Pronoun:
Ethnicity/race (optional):
Information is for reporting purposes only

Employment Information


Education and Interests Information

Know any languages other than English?:

Emergency Contact Information

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Personal References

Please provide the name and phone number for two references who are not family members.

First Reference

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Second Reference

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How Can You Help?

Areas of Interest:

Day/Days Available (Check all that apply):
Are there any reasons why you may have difficulty in performing any of the essential functions of the volunteer job for which you have applied?:
Are you presently carrying at least the minimum legally required auto insurance coverage?:

Photo Release

I do consent to and authorize the use and reproductions by Meals On Wheels of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, and exhibitions or for any other use for the benefit of the program.

Do you agree?:

Statement of Confidentiality

I do willingly promise to hold in confidence all matters that come to my attention in the line of duty at UR Medicine Home Care, including material from and about clients/patients and matters regarding colleagues. I will respect the privacy of the people who I serve and confer appropriately with those designated as my supervisors and/or administrators. Further, I will use in a responsible manner information gained in the course of my service at Visiting Nurse Service. I also certify that the information submitted on this application is true and accurate and I authorize UR Medicine Home Care to verify my references.

Background Check*: