Volun-Peer Mentor Form

Name:

Address:

City:

State:

ZIP:

Phone (land line):

Phone (mobile):

Email:

Date of Birth (MM/DD/YYYY):

Occupation (Former or Current):

Employer:

Work Phone:

Ext #:

Hours:

 Okay to call at work

Frequency:WeeklyEvery Other WeekMonthlyAs Needed

Available:MorningAfternoonEveningDuring the WeekWeekends

Do you routinely leave the area for an extended time at a particular time each year?
 NoYes

If so, when?

What service area?:AllNorthsideSouthsideOnalaskaHolmenWest SalemBangor

Do you have any health issues?

Any health-related restrictions?

Do you smoke? YesNo

If so, what do you smoke? CigarettesPipeOther

You must abstain while volunteering.

Do you have any allergies to...? DogsCatsBirds

Other?

Do you prefer no pets? No Pets

Please provide any information about yourself that will help in finding a lasting match.

Please list any previous mentoring experience:
 

Please list any previous caregiving experience:
 

Hobbies:

Favorite Books, Movies, TV Programs:

What do you enjoy talking about?:

Where do you (or would you) like to travel?:

Share any additional information here:
 

Provide support and encouragement to caregiver(s) of a recipient

Please check all that are of interest (Time given denotes acceptable length of service)

Phone, Email, Visiting Call, email or visit at least once a week to encourage and support (2-4 hrs/month)

Socialization Spend time with caregiver and recipient for socialization in the community (2-4 hrs/month)

Attend Lunch Bunch or Support Groups Provide transportation for caregiver and recipient (2-4 hrs/month)

Office Volunteer Assist in the office with mailings or newsletter, compiling mentor hours, etc. (2 hrs/month)

Other? (Time varies)

Full Legal Name:

Middle Name:

Former/Maiden Name:

Date of Birth:

Have you lived outside WI in the past three years? YesNo

If Yes, please list locations and dates of residency:

Have you completed Volun-Peer Orientation? YesNo

Date:

Have you voiced your questions? YesNo

Do you understand there is a risk involved when volunteering? YesNo

Do you understand you must volunteer within the guidelines/instruction of The Aging and Disability Resource Center of La Crosse County for the Peer Caregiver Support Program? YesNo

If you do not volunteer within the guidelines/instruction of The Aging and Disability Resource Center of La Crosse County for the Peer Caregiver Support Program, do you assume your own risk? YesNo

Note: Failure to volunteer within guidelines may make you ineligible to volunteer.