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Yakima and Selah Neighbors’ Network
PO Box 11691, Yakima, WA 98909
(509) 853-1917

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Make aging at home an affordable, viable and exciting option.
HomeVolunteer application



VOLUNTEER APPLICATION

 

Personal Information

Name:

Date:

Address:

 

City:

State: Zip:

Home Phone:

Cell Phone:

Email address:

 

Best Way to Contact You (Circle one)

Phone   Call      Text      Email

 

References (non-family)

 

Name:

Relationship:

Phone No.:

 

 

 

Name:

Relationship:

Phone No.:

 

 

 

 

Emergency Contact Information

 

Name:

Relationship:

Address:

 

City:

State:                Zip:

Email:

Phone No.:

 

 

 

Disclosures

Please share with us anything that we need to know that might direct or limit your volunteering opportunities, such as physical/mobility limitations, allergies (smoke, pets, dust ) or travel

frequently.

 

 

 

 

 

 

Please check days available to volunteer

 

Circle time of day available to volunteer

 

Sunday

 

Morning Afternoon Evening

 

Monday

 

Morning Afternoon Evening

 

Tuesday

 

Morning Afternoon Evening

 

Wednesday

 

Morning Afternoon Evening

 

Thursday

 

Morning Afternoon Evening

 

Friday

 

Morning Afternoon Evening

 

Saturday

 

Morning Afternoon Evening


 

Volunteer Interests: Please check ALL that apply.

 

 

In Home Support

 

Tech Support

 

Driving – rides to dr visits, shopping, etc.

 

Computer/web assistance

 

Light housecleaning

 

Social media support

 

Minor household repairs/maintenance

 

T.V., Cable, A/V Assistance

 

Pet Assistance

 

 

 

Sorting mail, bills, etc

 

 

 

Light gardening, yard work

 

 

 

In home visiting

 

 

 

Daily phone call check-in

 

 

 

Walking/exercise partner

 

 

 

Office & Organizational Support

 

Events

 

Clerical/Office Support

 

House Party/Info Session Host

 

Data Entry

 

Photography

 

Fundraising

 

Event Support

 

Marketing/Outreach

 

Social Event Planner

 

Telephoning

 

Teaching Class

 

Flyer/Poster Distribution

 

Lecture/Talk

 

 

Please provide any other information that you think is relevant, i.e. worked with blind people, master gardener, love of music, etc. Anything that would help match you to members.

 

 

 

Motor Vehicle Record Information (only required for volunteers providing transportation)

Within the past 5 years, have you been ticketed for any of the following?

Violation

Date

Violation

Date

Moving Violation

 

 

Reckless Driving

 

 

Aggressive Driving

 

 

DUI (past 15 yrs)

 

 

At Fault Accident

 

 

Other:

 

 

Attach copy of insurance card for your vehicle

Attach copy of drivers’ license

 

          Volunteer signature______________________________________________

 

 

For more information contact YSNN:

Phone: 509-853-1917

Email: ysnn.wa@gmail.com

Mail:  PO Box 11691, Yakima WA 98909