VOLUNTEER REGISTRATION FORM

DATE: _____________________________

PERSONAL INFORMATION

Miss, Mrs., Ms., Mr. ____________________________________________________

ADDRESS:_____________________________________________________________

(street) (city) (state) (zip)

PHONE: (_____) _____________________ (____) ____________________

(home) (work)

May we contact you at work? YES ______ NO _______

EMAIL: ______________________________ FAX: ___________________________

Person to contact in case of an emergency: ___________________________________

Relationship: __________________ Daytime phone: ____________________

VOLUNTEER PLACEMENT INFORMATION

The Fairfax Area Agency on Aging has a number of specific programs in which volunteers are involved. These are described in the accompanying “Wish List.” (Please check all that interest you.)

___Friendship, Senior

___Internship for School Credit (customized for each student)

___Nutritional Supplement Delivery

___Meals on Wheels

_____Driver _____Treasurer _____Driver Coordinator

______Program Coordinator

___On-Site Opportunities

___Pets on Wheels

___Telephone Reassurance

___Volunteer Guardianship

___Volunteer Home Services for Seniors

Other:__________________________________________________________________

(please describe)

EDUCATION/EXPERIENCE

INTEREST/SKILLS

� Computer � Public Speaking

� Drawing � Clerical

� Library � Writing

� Interviewer � Calligraphy

� Gardening � Interacting with People

� Home Repair � Editorial

� Program Management � Advocacy

� Research � Braille

� Photography � Transportation

� Graphics/Design � Languages (specify) _____ � Sign Language

What made you decide to work with and/or on behalf of older adults? What specific experiences have you had that would help you relate to an older client? This could include other volunteer activities, professional background, family, church, etc.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

AVAILABILITY

� One year or more OR approximate dates from _____ to _______

Check available days:

� Sunday � Monday � Tuesday � Wednesday

� Thursday � Friday � Saturday

Check available time:

� Morning � Afternoon � Evening

I would prefer:

� Regular schedule � Flexible schedule � On-call as needed

REFERENCES: One personal and one professional. Please list nonrelatives; local contacts are preferred.

Name_______________________________________________________________

Address_____________________________________________________________

Work Phone________________________________ Home Phone_______________

Name_______________________________________________________________

Address_____________________________________________________________

Work Phone________________________________ Home Phone_______________

Signature _____________________________________________

The information on the next page is required by our funding sources and is strictly confidential.

Magisterial District: Braddock _____ Dranesville ____

Hunter Mill ____ Lee ____

Mason ____ Mt. Vernon ____

Providence ____ Springfield ____

Sully ____

How did you hear about the AAA volunteer opportunities? Please circle:

Newspaper Radio TV Golden Gazette Phone Book

Other—list specific source if known: _______________________

FOR STATISTICAL PURPOSES*

DATE OF BIRTH: ____________________________________________________

RACE OR ETHNIC ORIGIN: White ____

Black/African American _____

American Indian ____

Oriental/Asian ____

Alaskan Native ____

Hispanic Origin ____

Unknown ____

*This information is strictly confidential.