Information About You

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Your Name

Birthdate (mm/dd/yyyy)

Contact Information

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Address

City

State
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Zip Code

Email

Phone Number (Primary)

Select Phone Type Home Work Cell Other

Alternate Phone (not required)

Select Phone Type Home Work Cell Other

Alternate Phone (not required)

Select Phone Type Home Work Cell Other

Best time to contact you

Preferred method of contact
Select Method Phone Email

What day/days are you available to volunteer? (Check all that apply)
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

What time of day would you be able to volunteer? (Check all that apply)
Mornings
Afternoons
Evenings

How many hours per month are you able to volunteer?

How would you like to volunteer? (Check all that apply)
As an individual
As a family
As a couple
With a friend

What type of volunteer position interests you? (Check all that apply)
Respite
Youth Programs
Office
Events
Talent Sharing

Special skills, training, interests or hobbies

How did you hear about us?
Friend
Newspaper
Faith Organization
FamilyMeans website
Other

References

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List three references. (At least 2 non-family members; please specify phone number given as day (d) or evening (e) number.) Please inform your references that we will be contacting them within the next 2 weeks after receipt of your application.

Name

Phone

Email

Reference 2

Name

Phone

Email

Reference 3

Name

Phone

Email

Have you ever been a family caregiver or respite provider?
Yes
No

Do you have an age preference for the person you care for?
Yes
No

If yes, do you prefer:
Children
Adults
Seniors

Are you comfortable providing respite in a smoking household?
Yes
No

Are you comfortable providing respite in a household with pets?
Yes
No

Do you have transportation?
Yes No

Please check all the areas in which you would be willing to provide respite care:
Afton
Cottage Grove
Forest Lake
Hugo
Lake Elmo
Lakeland
Mahtomedi
Marine-on-St.-Croix
Newport
Oakdale
Scandia
St. Paul Park
Stillwater/Bayport
Woodbury