IVC Volunteer Application

Contact Information

First Name

Last Name

Preferred Phone

Mobile Phone

Ex: 206-842-4441

Home Phone

Ex: 206-842-4441

Date of Birth

mm/dd/yyyy

Gender

Street Address

City

State

Zip Code

Previous Volunteer Experience

List any hobbies or interests

Allergies and Limitations

Do you smoke?

Are you willing to visit a smoker?

Are you allergic to pets?

Do you have any other allergies?

Do you have any physical conditions that would limit your volunteer activities?

If yes, please describe.

I could lift:

Driving Volunteer Opportunities

Do you have a valid driver's license?

Please upload a copy of your driver's license here.

Do you have current auto insurance?

Enter the year, make, and model of your vehicle.

Please upload your auto insurance policy here.

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship

References

Please list two personal references we may contact who are not family members and who do not live in the same household as you.

Reference 1: Name

Reference 1: Email

Reference 1: Relationship

Reference 2: Name

Reference 2: Email

Reference 2: Relationship

Disclosures and Signature

Have you ever been convicted for violation of any non-traffic laws?

I hereby disclose that I have or have not ever been convicted of any crime against persons:

I hereby disclose that I have or have not ever been convicted of crimes relating to the financial exploitation of any person.

I hereby disclose that I have or have not ever been found to have sexually or physically abused, assaulted or exploited any person.

I hereby authorize Island Volunteer Caregivers to request a background check by the WA State Patrol in support of the above disclosure, as well as a Driver's Abstract from the WA State Dept of Licensing, if I will be providing transportation. These will be done upon initial application, and at least biennially.

Enter your first name, last name, and today's date below.

Contact Information