Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home phone

(###)

###

####

Which volunteer role(s) are you most interested in?

Special Deliveries: Pick-ups, deliveries and errands

Phone Friends: Companionship calls

Rides

Shopping Escort

Technology Support

Other

When are you generally available to volunteer?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

If driving for Heart to Heart:

a. Do you have a valid driver's license?

Yes

No

b. Do you have your own insured vehicle to provide services?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Do we have your permission to do a background check?

Yes

No

Do you have a navigation device either on your phone or in your car?

Yes

No

If available, would you like to receive moderate mileage stipends?

Yes

No

Please check below to indicate that you understand your responsibilities as a Heart to Heart volunteer.

I have reviewed the Heart to Heart Volunteer Handbook.

Signature

By typing in your name below, you confirm that the above information is accurate, that you have read the Heart to Heart Volunteer Handbook, and that you understand and agree to all written and verbal information, including the confidentiality provisions and nondiscrimination policy.

First Name

Last Name