608.775.9999
4141 Mormon Coulee Road, La Crosse WI 54601
Name:
Address:
City:
State:
ZIP:
Phone:
Email:
Church:
Date of Birth (MM/DD/YYYY):
Occupation (Former or Current):
How did you hear about Causeway?
Do you receive...? SSI (Supplemental Security Income)SSDI (Social Security Disability Insurance)
Physician Determined Disability:CognitiveEmotionalPsychiatricPsychological Impairment(s)
Description:
Medical Disability:CHF (Congestive Heart Failure)COPD (Chronic Obstructive Pulmonary Disease)Macular DegenerationMultiple SclerosisCerebral PalsyParkinson's DiseaseEpilepsyLupusRheumatoid ArthritisKidney DiseaseCancerOther (describe below)
Mobility Aids:CaneWalkerWheelchair (must be able to transfer/toilet independentlyOther (describe below)
Other Health/Mobility Concerns:
Do you have a social worker? YesNo
Social Worker's name:
Social Worker's phone:
Social Worker's organization:
Do you receive medical assistance? YesNo
Other Agency or Personal Assistance:
Do you smoke? YesNo
If so, what do you smoke? CigarettesPipeOther
You must abstain while Volunteer present.
Do you have any pets? YesNo
If so, what type of pet(s)?
Your pet's name(s)?
If someone lives with you, what is his/her name?:
Relation:
Personal or Family contact:
Does this person help you? How?
SERVICES NEEDED:
Arts Buddy (Schedule available online or by mail - $2.50 per performance, tickets at Causeway)
Sports Buddy (Volunteer to attend College or Logger sports events with you, expense of ticket)
Errands
to
for.
Frequency:WeeklyEvery Other WeekMonthlyAs NeededOne Time
Date:
Time:
Until:
Outings (Spending time with a volunteer out in the community doing recreational activities)
Shopping
at
Assistance Needs:In StoreCarrying BagsPutting Away
Bookwork (Volunteer to help sort and organize papers for payment, correspondence or filing)
Indoor Chore
What is the chore?:
Materials needed must be supplied or paid for by recipient. Volunteer not responsible for any cost. **Due to lack of volunteers, Light Housekeeping or Laundry needs can be noted, but cannot be primary need
Outdoor Chore
Tools Needed:
Do you have these tools?YesNo
Causeway does not allow the use gas powered tools unless volunteer and recipient assume responsibility.
Reading (Volunteer to read a book, newspaper, magazine, etc to a person with vision loss)
Respite (Volunteer spends time with an individual while their caregiver has time alone)
Visits (Volunteer to visit in person or on the phone, do activities with you in your home)
Writing (Volunteer to assist with personal correspondence, seasonal or occasion cards, etc)
Vehicles you can get into:CarTruckSUVVan
Do you use?City BusCounty BusTransport Service
Provide any information about yourself that will help in finding a lasting volunteer match.
Hobbies:
Your interests:
Did you serve in the military? YesNo
Branch:
Where?
Share any additional information here:
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The Peer Caregiver Support Program connects Volun-Peer Mentors with caregivers of individuals diagnosed with Dementia for caring support, socialization and knowledge of local resources. • Volun-Peer Mentor form • Caregiver form • Care Recipient form
Support Causeway's mission of providing volunteer services without charge in La Crosse County
