Volunteer Intake Form

Name:

Address:

City:

State:

ZIP:

Phone:

Email:

Church:

Date of Birth (MM/DD/YYYY):

Occupation (Former or Current):

Employer:

Work Phone:

Ext #:

Hours:

 Okay to call at work

Frequency:WeeklyEvery Other WeekMonthlyAs NeededSubstitute Only

Available:MorningAfternoonEveningDuring the WeekWeekends

 SpringSummerFallWinter

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

If so, when?

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 recipient present.

Do you have any allergies to...? DogsCatsBirds

Other?

Do you prefer no pets? No Pets

Do you own a vehicle? YesNo

Vehicle type:CarTruckSUVVanOther

Make:

Model:

Color:

Drivers License Number:

State:

Restrictions:

Vehicle Insurance Company:

Policy Number:

Is your policy current? YesNo

If you don't have a vehicle, do you use?City BusTaxiBicycle

Other:

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

In what geographical area(s) are you willing to volunteer?
 NorthsideSouthsideOnalaskaHolmenWest SalemBangor

Please list any special training or skills you may have that pertain to volunteering:
 

Did you serve in the military? YesNo

Branch:

Where did you serve?

Hobbies:

Interests:

Share any additional information here:
 

Arts Buddy   Schedule available online or by mail - $2.50 per performance, tickets at Causeway

Sports Buddy   Attend College or Logger sports events with your match, expense of ticket

Errands   Bank | Post Office | Repair of Item | Pharmacy | Veterinary | Medical Appointments | Etc.

Shopping  Grocery | Clothing | Shoe | Household Items | Pet Needs | Health/Pharmacy | Holiday | Etc.

Are you willing to...?
 Shop from a list onlyOffer assistance in the storeCarry bagsPut items away

Indoor Home Chore Wash Windows | Storm/Screen | Light Bulb| Garden/Bushes | Light Repairs | Etc.

Materials needed must be supplied or paid for by recipient. Volunteer not responsible for any cost

Outdoor Home Chore Wash windows | Raking | Snow/Ice Treatment | Wedding | Pruning | Etc.

What tools do you have?

Causeway does not allow the use gas powered tools unless volunteer and recipient assume responsibility.

Reading Read a book, newspaper, magazine| Find Books on Tape | Library Outings | Etc.

Writing Correspondence | Assistance writing letters | Assistance writing seasonal/occasion cards

Bookwork Sorting Mail and Papers | Organizing Papers for Payment | Filing | Correspondence | Etc.

Visits Phone calls | Crafts | Baking | Cards/Board Games | TV Program/Movie | Scrap booking | Etc.

Outings  Drives | Food/Coffee | Points of Interest | Social Events | Movie | Parks | Walk | Church | Etc.

Causeway Office Volunteer | Newsletter | Fundraisers | Committee | Church Representative

Other?

Do you and will you maintain health insurance for yourself?

Do you and will you maintain vehicle insurance?

Please list your agent's name:

Company:

We screen all Volunteer and Recipient background information
Full Legal Name:

Former/Maiden Name:

Middle Name:

Date of Birth:

Have you lived outside WI? YesNo

Cities:

Have you completed Volunteer 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 Causeway Interfaith Volunteer Caregivers, Inc? YesNo

If you do not volunteer within the guidelines/instruction of Causeway Interfaith Volunteer Caregivers, Inc., do you assume your own risk? YesNo

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