myLegion.org Icon
Legion.org Icon Facebook Icon Twitter Icon YouTube Icon News Feed Icon

6050 W Mequon Rd, Mequon, WI

Howard J Schroeder Post 457

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

www.interfaithozaukee.org                                                                                                 

 

 

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?____________________________________________________________

 

 

Services You Can Provide: 

Client contact:                           

                                                 

Administrative Support:

____Transportation                      

 ____Snow Removal/Yard Care 

___ Clerical Assistance 

____Light Housekeeping              

 ____Paperwork & Bill Paying  

___ Public Speaking

____Home Repair & Odd Jobs 

 ____Friendly Visits & Calls        

___ Special Events

____Shopping and Errand-Running

 

 ____Respite Care                     

___ Vol. Recruitment

 

 Volunteer Matching Questions: 

 

  1. Previous volunteer experience: _____________________________________________________________________

 

________________________________________________________________________________________________ 

 

  1. What skills could you contribute as a volunteer: _________________________________________________________

 

________________________________________________________________________________________________

 

  1. Hobbies, interests: _______________________________________________________________________________ 

 

________________________________________________________________________________________________

 

  1. Languages spoken: ______________________________________________________________________________ 

 

  1. Do you smoke? _____Yes     ____No           Are you allergic to smoke? ____Yes     ____No 

 

  1. Are you allergic to pets? ____Yes     ____No 

 

  1. How far are you willing to drive? ____No Reasonable Limit     -OR-       ____ Miles From ________________________ 

 

  1. Are you willing to drive out of Ozaukee County? ____Yes     ____No     _____Occasionally 

 

  1. Generally, when are you available? ___ all year/seasons     ____summer only   __other______________________ 

 

  1. Please check the days and times you prefer to volunteer: 

 

û`ð‹È  ªªE@À}U{ÿÿ^ûc<°Eoxÿ ˆÀ¨Pàûéé[Ø«„ CanonMX870local€<�À¨P801168192in-addrarpa €<�À 3EEvening

 

 

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Morning

 

 

 

 

 

 

 

Afternoon

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Do you have a valid driver’s license?                             _____ Yes     _____ No

 

      Driver’s License Number ____________________________          Expiration Date ____________________________

 

      Car Make and Model _______________________________          Color ____________________________________

 

  1. Auto insurance company: _________________________________________________________________________

 

      Policy Number:_____________________________________        Expiration Date: ___________________________

 

  1. Do you have any criminal charges pending against you?   _____Yes      _____No

 

  1. 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.

 

  1. Name:__________________________________________ Relationship:____________________________________

 

Address: __________________________________________ City:                    State:    Zip:_______________

 

Phone: ____________________________________________Email:_________________________________________

 

 

  1. 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:                                                                                                               ___________________________________

<< Previous Page     Next Page >>

Legionsites | Sign In