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Senior Application
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First Name
Last Name

Personal Information
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country

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(ie. health, memory, or mobility concerns)

Contact Person In Case of Emergency
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Volunteer Preference
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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.
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