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Roberto Muniz
Michael Callan
Carol F Burt
Mary Lou Farmer
Anita Franzione
Donna V Lazartic
Gloria Zayanskosky
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VOLUNTEER OPPORTUNITIES
APPLICATION FOR VOLUNTEER WORK
First Name:
Last Name:
Address:
Address (Cont.):
City:
State:
Zip:
Date of Birth:
Now
Home Phone:
(
)
-
Cell Phone:
(
)
-
Business Phone:
(
)
-
Email:
In an emergency please contact:
Name/Relationship:
Emergency Phone:
(
)
-
Building Preference:
Parker at Landing Lane:
Parker at River Road:
Parker at Stonegate:
Pavilion:
Previous volunteer experience:
Specific needs related to this volunteer experience:
Preferences:
Group Activities:
Individual Activities:
Administrative:
The Country Store:
Are you willing to assist residents at meal time?:
Yes
No
Please indicate your availability:
All Year:
Summer Only:
Internship:
Other:
Mornings:
Afternoons:
Evenings:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
How were you refered to Parker Home:
Staff Member:
Volunteer:
Parker Home Website:
Family Member:
Internet:
Other:
Interests, talents and hobbies:
Art History:
Arts and Craft:
Bible Study:
Bingo:
Bird Watching:
Bridge/Pinochle/Blackjack/Poker:
Calligraphy:
Carpentry/Woodworking:
Checkers/Chess:
Church Services:
Clerical:
Collecting:
Computer:
Cooking:
Crocheting/Knitting:
Crossword Puzzles:
Exercise:
Dance:
Decorating:
Discussion Group:
Dramatics:
Flower Arranging:
Gardening:
Hair Styling:
Lawn Games:
Letter Writing:
Leather Crafting:
Music Appreciation:
Movies:
Needlepoint/Embroider:
Newsletter:
Pets:
Photography:
Poetry:
Political Group:
Public Speaking:
Reading:
Science:
Singing:
Sports:
Story Telling:
Travel:
Trips:
Walking:
Visiting:
Other:
Do you plan to play an instrument:
Yes
No
If yes what type?:
Would you be available for special events on occasional basis?:
Yes
No
Have you ever worked with people who have dementia?:
Yes
No
References:
First Name:
Last Name:
Phone Number:
(
)
-
Address:
Address (Cont.):
City:
State:
Zip:
First Name:
Last Name:
Phone Number:
(
)
-
Address:
Address (Cont.):
City:
State:
Zip:
Additional comments/needs:
Enter Security Code:
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