Thank you for your interest in volunteering with Senior Services!

Senior Services relies heavily on a dedicated team of community volunteers to help carry out our mission.

Please complete this secure online volunteer application to get started!

Please see Student Application if seeking an internship at the Williams Adult Day Center.

Contact and Personal Information

Please tell us a little about yourself!

Please select a salutation: *

First Name *

Middle Name *

Last Name *

Preferred Name/Nick Name (if applicable):

Please select a gender: *

Current Street Address *

Address Line 2

City *

State *

Zip Code *

How long have you lived at this address?

From Month *

From Year *

Previous Street Address *

Previous Address Line 2

Previous City *

Previous State *

Previous Zip Code *

How long did you live at this address?

From Month *

From Year *

To Month *

To Year *

Cell Phone Number *

Alternate Phone Number (Optional)

Email Address *

Volunteer's Date of Birth: * +

What is your preferred method of contact? *

Phone call

Email

Would you like to stay connected with ways to support our organization? *

Yes

No

Are you volunteering as a member of an organization or group? *

No

Yes, which one? Yes, which one?

Are you affiliated with a faith or civic group? If so, please share below:

I am currently: * 🛈

Please list your employer? *

Please list your school? *

Have you ever been convicted of a crime? *

No

Yes, please describe: Yes, please describe:

Emergency Contact

Please let us know who we should contact in the event of an emergency.

Please select a salutation *

Emergency Contact First Name *

Emergency Contact Last Name *

Phone Number *

Relationship to Volunteer *

Availability and Preferences

Let us know when you're available to volunteer and what you'd most like to do!

Please list your special skills, hobbies and interests (office, people, public speaking, technical, etc) and be as specific as possible: *

Are you interested in volunteering with any of the following programs? Please check all that apply. *

Please note this application should only be submitted if you are interested in volunteering with the Williams Adult Day Center. If you are interested in completing an internship or other academic program requirement at the Center please submit a Student Application here.

When are you available to volunteer? (Check all that apply) *

Please indicate the best time of day for you to volunteer *

How many days each month are you available to volunteer? *

Do you have a geographic preference for volunteering? *

How did you hear about Senior Services? Please check all that apply. *

Please indicate which college/university website or event you heard about us from.

Please indicate which social media platform you heard about us on.

Please indicate the other website(s) where you heard about Senior Services.

Volunteer Match

HandsOn NWNC

Love out Loud

Other: Other:

Please indicate the community event where you heard about Senior Services.

Please indicate the place of worship where you heard about Senior Services.

Background Screening Consent Form

Senior Services may obtain from Sterling Volunteers, 113 South College Avenue, Fort Collins, CO, 80524, (855) 326-1860. www.sterlingvolunteers.com, a consumer report and/or an investigative consumer report that contains background information about you in connection with volunteerism. Sterling Volunteers may obtain further reports throughout your volunteerism so as to update your report without providing further disclosure or obtaining additional consent.
The background report may contain information about your character, general reputation, personal characteristics and mode of living. The background report may include, but is not limited to, credit reports and credit history information; criminal and other public records and history; public court records; motor vehicle and driving records; and Social Security verification and address history, subject to any limitations imposed by applicable federal and state law. This information may be obtained from public record and private sources, including credit bureaus, government agencies and judicial records, and other sources. If an investigative consumer REPORT is obtained, in addition to the description above, the nature and scope of any such REPORT will be for personal references.
I have read the Disclosure above regarding Volunteer Background Report provided by Senior Services and this Authorization to Obtain Volunteer Background Report. By my signature below, I hereby consent to the preparation by Sterling Volunteers, a consumer reporting agency located at 113 South College Avenue, Fort Collins, CO, 80524, (855) 326-1860,www.sterlingvolunteers.com, of background reports regarding me and the release of such reports to Senior Services, to assist the Senior Services in making a volunteer decision involving me at any time after receipt of this authorization and throughout my volunteerism, to the extent permitted by law. To this end, I hereby authorize, without reservation, any state or federal law enforcement agency or court, educational institution, motor vehicle record agency, credit bureau or other information service bureau or data repository, to furnish any and all information regarding me to Sterling Volunteers and/or Senior Services itself, and authorize Sterling Volunteers to provide such information to Senior Services. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. I acknowledge receipt of a copy of the Consumer Financial Protection Bureau’s “A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT.

Volunteer's signature *

clear

Date *

Automobile Insurance Information

All Meals-on-Wheels volunteers use their own transportation to deliver meals. Please complete the following information for the vehicle you most plan to use:

I agree to maintain current insurance and a valid driver's license. If I use my personal automobile in my volunteer service, I understand that I must keep automobile liability insurance in effect equal to the minimum limits required by North Carolina (Senior Services, Inc. and its insurance provider recommend that you carry 100K/300K liability limits on your personal auto policy.) I will inform Senior Services of any future changes. Please indicate that you've read and agree to this statement: * 🛈

clear

Liability Waiver

By signing this document, I voluntarily waive, release, and hold harmless Senior Services of any liability due to accident or illness while performing volunteer services. I also agree for myself and for any child/minor volunteer who I am responsible for to follow all rules, procedures, and instructions that apply to my role. If I am allowing a child/minor to participate in the activity, I agree that I am a parent, legal guardian, or am otherwise responsible for the child/minor who is participating, and I release, waive, and discharge any legal rights that I may assert on behalf of them volunteering. Furthermore, I understand that Senior Services provides no compensation, insurance, or worker’s compensation coverage for me or for my child.

Sign here to acknowledge you have read and agree to the Senior Services, Inc. Liability Waiver: * 🛈

clear

Confidentiality Statement

The confidentiality of program participants and volunteers is very important to us.

Please read the below statement carefully:

Senior Services, Inc. respects the privacy of all program participants. All volunteers are expected to maintain the confidentiality and the privacy of each participant, both past and present. Information regarding any program participant shall not be disclosed in a form which identifies the participant to any other person or agency. Volunteers will refrain from discussing participants with anyone except appropriate staff.

Sign here to acknowledge you have read and agree to the Senior Services, Inc. Confidentiality Statement: * 🛈

clear

Type your name to acknowledge you have read and agree to the Senior Services, Inc. Confidentiality Statement: *

Today's Date: * +

Thank you for your interest in volunteering with Senior Services, Inc.!

Please type your name below to indicate that the information provided in this application is true and accurate to the best of your knowledge.

The next step once you finish this application is to complete the orientation. A pop up box will give you the link once this application is submitted.

If you have any questions, please contact:

Tyler Smith, Volunteer and Community Relations Coordinator

tsmith@seniorservicesinc.org or

336-721-6961.

Name: *

Today's Date: * +