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Senior Companion Program

Volunteer Application

Sponsored by The Senior Source

3910 Harry Hines Blvd., Dallas, TX 75219

Phone: (214) 823-5700

Fax: (214) 826-2441

Date of Application

Step 1: Your Contact Details

First Name

Middle Name

Last Name

Home Phone

Cell Phone

Email

Mailing Address

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

Step 2: Tell Us About Yourself

	Response
Are you a U.S. Veteran?	YesNo
Is your spouse a U.S. Veteran?	YesNo
Gender:	FemaleMaleOther
What is your primary mode of transportation?	CarBusParatransitWalk/CarpoolOther
Can you drive?	YesNo

Please provide your Driver's License details here:

State

Expiration Date

Driver's License #

What is your preferred language?

What languages do you speak other than English (select all that apply)

Spanish	French	Vietnamese
Other

Please list other languages here:

For background check purposes ONLY. Please complete the following information:

Social Security #

Date of Birth (MM/DD/YYYY)

Birthplace

Height

feet

Height

inches

Weight

lbs

Eye Color

Hair Color

Are you Hispanic or Latino?

Yes

No

Why would you like to become a Senior Companion Program volunteer?

How did you hear about the Senior Companion Program?

Please indicate your preferred volunteer time

MorningAfternoonNo Preference

Step 3: References

Please list three character references that are NOT related to you. We WILL be contacting each reference listed:

Reference 1

Name

Phone #

Relationship

How long have you known reference?

Reference 2

Name

Phone #

Relationship

How long have you known reference?

Reference 3

Name

Phone #

Relationship

How long have you known reference?

Step 4: Emergency Contact

Emergency Contact

First Name

Last Name

Phone #

Relationship to you

Street Address

State

City

Zip Code

Step 5: Employment and/or Volunteer History

Please provide details of your current or previous employment or volunteer positions below. Add as many versions of this section as desired using the BLUE "Add another response" link below (last 4 are preferred).

Employment and/or Volunteer History

Company/Organization Name

Position

From (Year)

To (Year)

Step 6: Confirmation & eSignature

Have you ever been convicted of, plead guilty, or "no contest" to a crime that has or has not been expunged or removed from your record? A full disclosure is to your advantage because your record does not automatically disqualify you for acceptance in the program. However, failure to admit convictions may result in the disqualification of your application.

YesNo

If yes, please explain.

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Contact Information