Valley Senior Living Volunteer Application Form

Please complete this application form if you are interested in becoming a Valley Senior Living volunteer. Once you complete the form, click the Continue button at the bottom.

Name and address

First name:

Last name:

Street 1:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Emergency Contact

First name:

Last name:

Home phone:

Relationship:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Type:

Date of birth:

* (year optional)

Gender:

Availability

Please indicate the days and times you are usually available to volunteer.

Why Volunteer at Valley Senior Living?

Shadow PT:

Shadow OT:

Availability

Part of a group?:

Assignment Preference:

Myra Cafe

Tufte Manor

VSL on 42nd

VSL on Columbia

References

First name:

Last name:

Home phone:

Work phone:

Cell phone:

HIPAA

Form will be emailed to you upon submission of this application.

Background Check

Form will be emailed to you upon submission of this application.

Signature

Print Name:

Sign Date:

Agreement

I certify that the statements made in this volunteer application are true and correct. I understand by checking agree, this indicates my approval to complete a background check. I also agree to the rules and regulations of Valley Senior Living.

Valley Senior Living is not obligated to provide a placement, nor am I obligated to accept the volunteer position offered.

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.

I Agree