Date of Birth (MM/DD/YYYY):
Occupation (Former or Current):
Okay to call at work
Frequency:WeeklyEvery Other WeekMonthlyAs NeededSubstitute Only
Available:MorningAfternoonEveningDuring the WeekWeekends
Do you routinely leave the area for an extended time at a particular time each year?
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
Do you prefer no pets? No Pets
Do you own a vehicle? YesNo
Drivers License Number:
Vehicle Insurance Company:
Is your policy current? YesNo
If you don't have a vehicle, do you use?City BusTaxiBicycle
How did you hear about Causeway?
Please provide any information about yourself that will help in finding a lasting match.
In what geographical area(s) are you willing to volunteer?
Please list any special training or skills you may have that pertain to volunteering:
Did you serve in the military? YesNo
Where did you serve?
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?
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
Do you and will you maintain health insurance for yourself?
Do you and will you maintain vehicle insurance?
Please list your agent's name:
We screen all Volunteer and Recipient background information
Full Legal Name:
Date of Birth:
Have you lived outside WI? YesNo
Have you completed Volunteer Orientation? YesNo
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.
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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
4141 Mormon Coulee Rd
La Crosse, WI 54601
Causeway Interfaith Volunteers, Inc. is a 501(c)(3) non profit organization. Donations are tax deductible for federal income tax purposes as charitable contributions.