Brownsburg Older Adult Alliance, Inc.

Volunteer as: *

Individual

Business

Date of Birth *

(mm/dd/yyyy)

Name *

First Name

Last Name

Organization/Employer

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

Verify Email

Home Phone

Cell Phone

Preferred Way of Contact *

Email

Cell Phone

Home Phone

Best Day/Time to Call

Please list any languages, other than English, that you can speak or understand (including sign language)

Do you have any medical certificates or training? ex. CPR, CNA *

Please list 1 reference other than relatives.

Volunteer Reference *

(Name, Relationship, Phone & Email and Year Acquainted)

Volunteer Interests

Applying for a volunteer position in order to fulfill a class or organization requirements?* *

Yes

No

If yes, please describe how many hours and the date to complete.

*Due to BOAA policy, we cannot fulfill court-ordered Community Service Hours.

Other Volunteer Interest Description

Member Preferences *

Male

Female

Either is Okay

Days available? *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Time of Day? *

Mornings

Afternoons

Evenings

How often do you want to volunteer? *

Weekly

Monthly

As Needed

Do you have transportation? *

Yes

No

What is your means of transportation to volunteer if no driver's license?

Have you ever been convicted of a crime? *

Yes

No

(Including any felonies or misdemeanors) BOAA policy prohibits any type of criminal history.

Emergency Contact (name & phone number)

Your ID will be checked and/or copied upon volunteer orientation for all BOAA Programs.

I acknowledge and agree that all information provided herin is accurate and try and hereby authorize Brownsburg Older Adult Alliance, LLC (BOAA) to verify such information, contact references, and conduct a criminal background check. I understand I will not be paid for my services, as this is strictly volunteer work. I have read and understand the above statements. Submission of the form is proof of my agreement.

BOAA is an equal opportunity volunteer organization. All volunteer applicants are considered without regard to race, religion, sex, age, disability, national origin, or any other legally protected status.

Volunteer Enrollment

Please list 1 reference other than relatives.

Volunteer Interests

*Due to BOAA policy, we cannot fulfill court-ordered Community Service Hours.