Meals on Wheels Volunteer Form

First Name Middle Name Last Name Email Phone Number Street Address City State Zip Code Date of Birth Please enter your date of birth in XX/XX/XXX format. Preferred Pronouns He She They Ethnicity/Race (Optional) African American Asian Caucasian Hispanic Other Are You Retired? Yes No Do you know any languages other than English? Yes No Other Education or Enrichment Please list or describe. Current/Previous Volunteer Experience Please list or describe. Emergency Contact Name Emergency Contact Phone Number Reference #1 Name Please provide the name of a reference that is not a family member. Reference #1 Phone Number Please provide a phone number for the reference listed above. Reference #2 Name Please provide the name of a reference that is not a family memeber Reference #2 Phone Number Please provide a phone number for the reference listed above. Areas of Interest Meals on Wheels Delivery Pet Food Program Clerical Service Please check all areas you are interested in. Availability Monday Tuesday Wednesday Thursday Friday Please select the day(s) you are available. How did you hear about Volunteer Services? Please describe how you heard about this opportunity. Are there any reasons why you may have difficulty performing any of the essential functions of the volunteer job for which you have applied? Yes No Are you carrying at least the minimum legally required auto insurance coverage? Yes No Photo Release Yes, I agree. 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. Statement of Confidentiality Yes, I agree to a background check. 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.