Interfaith Caregivers of Ozaukee County is a nonprofit 501c3 headquartered in Grafton with the mission: “Enabling seniors, including those with limited mobility, to remain independent in their own homes”. Through a group of registered volunteers, we provide free transportation services to Ozaukee County seniors that need a ride to hospital appointments, clinic appointments, the pharmacy, and grocery store. Unfortunately, the number of seniors that need transportation services is outpacing the number of volunteers we have to provide this service, and that was the reason for my presentation. If Post 457 has any members that would be interested in volunteering their time to help, be it an hour a week or an hour a month, it would be very helpful. Attached is a Volunteer Application with the hope that someone may be interested.
885 Badger Circle, Grafton WI 53024 Volunteer Application
(262) 376-5362
Last Name______________________________________ M.I._____ First Name________________________________
Address________________________________________ City______________________ State______ Zip___________
Home Phone (___)________________Cell Phone(___)___________________Email_____________________________
Birthdate _____/______/_______ Gender (circle one) M / F
Occupation______________________________________ Work Phone (_____)________________________________
Religious Afflilation________________________________Congregation_______________________________________
How did you hear about Interfaith Caregivers?____________________________________________________________
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Services You Can Provide: Client contact: |
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Administrative Support: |
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____Transportation |
____Snow Removal/Yard Care |
___ Clerical Assistance |
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____Light Housekeeping |
____Paperwork & Bill Paying |
___ Public Speaking |
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____Home Repair & Odd Jobs |
____Friendly Visits & Calls |
___ Special Events |
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____Shopping and Errand-Running
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____Respite Care |
___ Vol. Recruitment |
Volunteer Matching Questions:
- Previous volunteer experience: _____________________________________________________________________
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- What skills could you contribute as a volunteer: _________________________________________________________
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- Hobbies, interests: _______________________________________________________________________________
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- Languages spoken: ______________________________________________________________________________
- Do you smoke? _____Yes ____No Are you allergic to smoke? ____Yes ____No
- Are you allergic to pets? ____Yes ____No
- How far are you willing to drive? ____No Reasonable Limit -OR- ____ Miles From ________________________
- Are you willing to drive out of Ozaukee County? ____Yes ____No _____Occasionally
- Generally, when are you available? ___ all year/seasons ____summer only __other______________________
- Please check the days and times you prefer to volunteer:
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- Do you have a valid driver’s license? _____ Yes _____ No
Driver’s License Number ____________________________ Expiration Date ____________________________
Car Make and Model _______________________________ Color ____________________________________
- Auto insurance company: _________________________________________________________________________
Policy Number:_____________________________________ Expiration Date: ___________________________
- Do you have any criminal charges pending against you? _____Yes _____No
- Were you ever convicted of a crime? _____ Yes _____ No
References
Please provide us with the names of two people, not related to you, who have known you for at least one year and can serve as a reference.
- Name:__________________________________________ Relationship:____________________________________
Address: __________________________________________ City: State: 
Zip:_______________
Phone: ____________________________________________Email:_________________________________________
- Name:__________________________________________ Relationship: ___________________________________
Address: __________________________________________ City: State: Zip:_______________
Phone: ____________________________________________Email:_________________________________________
In Case of Emergency Contact:
Name:___________________________________________ Relationship: ____________________________________
Address: __________________________________________ City: State: Zip:_______________
Phone: ____________________________________________Email:_________________________________________
Understanding and Signature:
The information I have provided on this application is truthful and accurate to the best of my knowledge. I understand that a further review of my application may include a criminal background check conducted by Interfaith Caregivers of
Ozaukee County. Furthermore, I understand that providing false information omitting information or an unfavorable result of a criminal background check, may result in denial of volunteer service from Interfaith Caregivers of Ozaukee County.
Signature: _____________________________________________________Date: 
Please return this application to address on the first page.
For office use only: Date orientation/training completed: ___________________________________