Befrienders · Senior Application

Name

*

First Name

Last Name

Email

Verify Email

Personal Information

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Birthdate

(mm/dd/yyyy)

Gender

*

Smoker

*

How did you hear about Befrienders?

*

Who is filling out this application (name and phone)?

*

Highest educational degree achieved?

*

Hobbies or Interests

*

Life Experiences (job, family, volunteer, etc.)

*

Briefly tell why you are interested in Befrienders

*

Special Considerations

(ie. health, memory, or mobility concerns)

Other Services Received

Contact Person In Case of Emergency

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

*

Email

Verify Email

Relationship

*

Volunteer Preference

Age

*

Younger Visitor

Older Visitor

No Preference

Gender

*

Male

Female

No Preference

I give permission to Befrienders, Inc. to use my photograph for promotional use (promoting our program helps us stay in operation - please help us reach out to others in this way). Please initial if permission is given:

Permission

Prior to allowing a Befriender volunteer visitor to drive anyone in our program, we require them to provide a valid driver's license, proof of liability insurance, and sign our "Volunteer Driving Agreement," which can be provided to you upon request. Please sign and date below to agree to the following if there is any chance that our Befriender visitor will be driving you anywhere: I knowingly and voluntarily have made a request to allow my Befrienders volunteer visitor (hereafter called Befriender) to drive me in their personal vehicle, and I do so at my own risk. In consideration for permission to allow my Befriender to drive me, I waive and release Befrienders and its affiliates from any and all liability for personal injury, death, and/or damage or loss of my personal property occurring while driving with my Befriender.

Electronic Signature

*

Date

*

(mm/dd/yyyy)