Care Partners of Cook County · Volunteer Application-Senior Rides

Applicant Information

Name

*

First Name

Last Name

Mailing address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Physical address (if different from mailing address)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email

*

Verify Email

*

Preferred phone

*

Okay to text?

*

Yes

No

Alternate phone

Okay to text?

Yes

No

Your employer

Occupation

Work phone

Okay to call you at work?

Yes

No

Emergency Only

*********************************************

The following information is required for background check

Have you lived in Minnesota for the last five years?

*

Yes

No

In no, please list address(es) for the last five years and dates of residence for each

Aliases used (i.e. maiden name)

Race

*

Asian or Pacific Islander

African American

Native

White

Unknown/Other

Hair color

*

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Your Emergency Contact Information

Emergency contact name

*

First Name

Last Name

Relationship to you

*

Phone

*

Address

*

Email

Verify Email

Personal References

Please provide two personal references who are not family members. Include complete mailing addresses, as references may be verified by phone or mail.

Reference #1

Name

*

First Name

Last Name

Phone

*

Mailing address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

How do you know this person?

*

Number of years known

*

Reference #2

Name

*

First Name

Last Name

Phone

*

Mailing address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

How do you know this person?

*

Number of years known

*

Availability

Would you consider volunteering on a weekend?

*

Yes

No

Weekend availability notes

Would you consider volunteering in the evening?

*

Yes

No

Evening availability notes

In which geographic areas are you willing to volunteer?

*

City of Grand Marais

Gunflint Trail

West End (Lutsen/Tofte/Schroeder)

East End (Croftville/Hovland)

Grand Portage

About You

Do you have any physical restrictions?

*

(i.e. weight bearing limits, mobility issues, etc.)

Are you a U.S. Veteran?

*

Yes

No

Branch of service

Do you know a language other than English?

*

Yes

No

Language

Education/special training

Previous volunteer experience

*

Previous experience with older adults

*

May we contact you regarding emergency (last-minute) rides?

*

Yes

No

May we contact you regarding rides to Duluth?

*

Yes

No

Do you have a Commercial Driver's License (CDL)?

*

Yes

No

Which class or classes?

Class A

Class B

Class C

Does your vehicle have 4WD/AWD?

*

Yes

No

Vehicle type

*

SUV

Van

Truck

Sedan

Make/model of your vehicle

*

I certify that...

I currently carry auto insurance

Name of insurance company

I will maintain a minimum of $100,000 in liability coverage

I have incurred no more than 1 traffic ticket or accident in the last 3 years

Thank you!

A copy of this application will be available at your in-person meeting for your review. You will be asked to sign a statement of declaration certifying that the information you have provided on this application is true.