Individual Volunteer Application

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Individual Volunteer Application

Today's Date(Required)

MM slash DD slash YYYY

Personal Information

Sex

Male

Female

Date of Birth(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Business Phone

Email(Required)

Emergency Contact(Required)

Emergency Contact Phone(Required)

Volunteer Preferences

Location(s)(Required)

Check all that apply

Parker at Landing Lane (New Brunswick)

Parker at Monroe (Monroe Township)

Parker at Monroe (Adult Day Center)

Parker at River Road (Piscataway)

Parker at Stonegate (Highland Park)

Parker at Somerset

Pavilion (Highland Park)

Previous Volunteer Experience

Specific Needs Related to This Volunteer Experience

Services:(Required)

Resident/Participant Engagement

Rehabilitation

Administrative/Clerical

Pet Visits/Therapy

Other

Check all that apply.

Other Service(s):(Required)

Availability

Please indicate which days and times you're available to volunteer (example: 12pm - 3pm). Leave blank if you can't volunteer that day.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How Often Would You Like to Volunteer?(Required)

Once a Week

Every Other Week

Once a Month

Other

Would You Be Available for Special Events On Occasion?(Required)

Yes

No

Interests, Talents and Hobbies

Please Indicate Your Interests, Talents and Hobbies(Required)

Discussion Group

Arts and Craft

Bible Study

Bingo

Bridge/Pinochle/Blackjack/Poker

Board Games / Crossword Puzzles

Reading/Writing/Poetry

Clerical/Computer

Music/Singing

Cooking

Crocheting/Knitting

Exercise

Dance

Art History

Science

Trips/Travel

Walking

Visiting

Check all that apply.

Do You Play an Instrument?(Required)

Yes

No

What Type(s)?(Required)

Have You Ever Worked With People Who Have Dementia?(Required)

Yes

No

Do You Prefer...(Required)

One-on-One Interactions

Small Group Activities

Large Group Activities

References

Name(Required)

First Last

Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Additional Comments/Needs

Δ

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