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

Say YES to staying in your home.

Say YES to Community! Come together with others to improve life for all of us.

Say YES to give and receive personal help with the YESneighbors network.

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

 

       

 





RELEASE OF LIABILITY & VOLUNTEER AGREEMENTS

 

By submitting this application, I affirm that the facts set fort in it are try and complete. 

By initialing statements below, I agree to the following YSNN policies: 

_____              I will offer my time without monetary compensation.

_____              I understand that my own personal or professional business will not benefit   financially or in any other way
from the volunteer service that I will perform.

_____              I agree to conform to all of the YSNN procedures and regulations.

_____              I understand that if I am accepted as a volunteer, any false statements, omissions,  or other misrepresentations made
by me on this application may result in dismissal.

_____              I authorize YSNN to contact my references and perform a background check

_____              I agree to indemnify YSNN against and hold it harmless from all loss and expense  arising out of any act, neglect or fault on my part.

_____              I agree to fill out a volunteer service report within 2 days of each volunteer service

_____              Finally, as a YSNN volunteer, I understand it is imperative to protect the confidentiality of all information pertaining
to any YSNN member, non-member, 
volunteer or client associated with YSNN, including any identifying information

                        about them, including the unauthorized possession, use, copying, reading or disclosure of applicable records, ledgers or files. 

 

Your signature indicates your agreement to adhere to YSNN’s volunteer agreement if placed as a volunteer.  YSNN is not obligated to provide a placement, nor are you obligated to accept the position offered.  The information you have submitted will not be given to any other parties without your permission. Volunteers are covered through the state for industrial insurance (workman’s comp) and in order to report your hours and have you covered, your social security number is needed.  Please provide below.   Initial and sign in the appropriate places. 

 

______            I have read the volunteer policies document and agree to its terms. 

______            I certify that the information given on this form is accurate to the best of my knowledge.

 

 

_____________________________________________                              _________________

Signature of applicant                                                                                           Date

 

______________________________________________________________________________

Print Name                                                                              Social Security Number

 

For more information contact YSNN:

Phone: 509-853-1917

Email: ysnn.wa@gmail.com

Mail:  PO Box 11691, Yakima WA 98909