Application for youth ages 15 to 17 years of age intersted in volunteering with Senior Services!
 
 
Please complete this secure online application to get started!
 
 
 

Contact and Personal Information

For other potential opportunities at Senior Services, please contact Holly Beck, Volunteer and Community Engagement Manager at hbeck@seniorservicesinc.org or 336-721-3411.
Please tell us a little about yourself!
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Have you ever been convicted of a crime? *
 

Parental or Guardianship Information

Please provide information for one parent or guardian.
Is this your emergency contact? *

Requirements and Availability

Let us know your specific academic requirements (if applicable) and when you're available to join us!
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When are you available? (Check all that apply) *
What program are you interested in? (Check all that apply) *
How did you hear about Senior Services? Please check all that apply. *
 

Emergency Contact

Please let us know what adult we can contact in the event of an emergency. 

Liability Waiver for Youth and Guardian

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.
Youth sign here to acknowledge you have read and agree to the Senior Services, Inc. Liability Waiver: * *
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Parent or guardian sign here to acknowledge you have read and agree to the Senior Services, Inc. Liability Waiver: * *
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Submit

Thank you for your interest in volunteering with Senior Services! 
 
Please type your name below to indicate that the information provided in this application is true and accurate to the best of your knowledge. 
 
You will be contacted shortly about your Student Application. 
 
If you have any questions please reach out to:
 
Holly Beck, Volunteer and Community Engagement Manager
hbeck@seniorservicesinc.org or
336-721-3411.
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