Volunteer Application

Full Name *

DOB *

Gender *

Male

Female

Prefer not say

Address *

City *

State *

Zip Code *

Phone *

Do you use text messaging?

Yes

Email *

Emergency Contact *

Relationship *

Phone *

Emergency Contact *

Relationship *

Phone *

Are there physical condition(s) that should be considered when arranging volunteer assignments for you?

Special Interests, Hobbies, Activities

Are you a veteran? *

Yes

No

Do you have a local church affiliation? (NOT required)

Yes

Are you fully vaccinated against COVID-19?

Yes

Would you work with clients who are not vaccinated?

Yes

Are you willing to drive to St. Louis? *

Yes

No

Are you willing to visit in a home with pets? *

Yes

No

Are you willing to visit a smoker? *

Yes

No

Hours Available *

REFERENCES: PLEASE PROVIDE US WITH THE NAMES OF 3 PERSONS, NOT RELATED TO YOU, WHO HAVE KNOWN YOU FOR AT LEAST ONE YEAR AND CAN SERVE AS REFERENCES. INDICATE THEIR RELATIONSHIP TO YOU.

Name *

Relationship *

Phone *

Name *

Relationship *

Phone *

Name *

Relationship *

Phone *

A Neighbor's Independence Depends on You