Home Care / Meals on Wheels / Meals on Wheels Volunteer Form

Meals on Wheels Volunteer Form

Meals On Wheels Service Area

One county service area map

place field "FirstName" below

To protect the safety and security of those we serve UR Medicine Home Care will conduct reference and background checks for all potential volunteers. Your signature on the Authorization of Disclosure form authorizes UR Medicine Home Care to conduct a background check to obtain information through criminal record inquiries, public records, and driving record.

If you would like to volunteer for Meals On Wheels, please fill out the form below.

Your Information

First Name*

place field "MiddleName" below

Middle Name*

place field "LastName" below

Last Name*

place field "Email" below

Email Address

place field "Phone" below

Phone Number*

place field "StreetAddress" below

Street Address*

place field "City" below

City*

place field "State" below

State*

place field "ZipCode" below

Zip Code*

place field "DOB" below

Date of Birth*

place field "PreferredPronoun" below

Preferred Pronoun

He She They

place field "Ethnicity" below place field "Retired" below Information is for reporting purposes only

Employment Information

Retired

Yes No

place field "Employer" below

If Employed, Employer's Name

place field "Languages" below

Education and Interests Information

Know any languages other than English?

Yes No

place field "Languagesknown" below

If yes, which languages?

place field "Educationother" below

Other Education or Enrichment

place field "Experience" below

Previous/Current Volunteer Experience

place field "EmergencyName" below

Emergency Contact Information

Emergency Contact Name*

place field "EmergencyPhone" below

Phone*

place field "ReferenceName1" below

Personal References

Please provide the name and phone number for two references who are not family members.

First Reference

Reference #1 Name*

place field "ReferencePhone1" below

Phone*

place field "ReferenceName2" below

Second Reference

Reference #2 Name*

place field "ReferencePhone2" below

Phone*

place field "AreasInterest" below

How Can You Help?

Areas of Interest

Meals on Wheels delivery Kitchen - meal preparation and packaging Pet Food Program Clerical Service

place field "Days" below

Day/Days Available (Check all that apply)

Monday Tuesday Wednesday Thursday Friday

place field "How" below

How did you hear about Volunteer Services?

place field "Reasons" below

Are there any reasons why you may have difficulty in performing any of the essential functions of the volunteer job for which you have applied?

Yes No

place field "IfYes" below

If "Yes", please explain

place field "Insurance" below

Are you presently carrying at least the minimum legally required auto insurance coverage?

Yes No

place field "Photo" below

Photo Release

I do consent to and authorize the use and reproductions by Meals On Wheels of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, and exhibitions or for any other use for the benefit of the program.

Do you agree?

I Agree

place field "BackgroundCheck" below

Statement of Confidentiality

I do willingly promise to hold in confidence all matters that come to my attention in the line of duty at UR Medicine Home Care, including material from and about clients/patients and matters regarding colleagues. I will respect the privacy of the people who I serve and confer appropriately with those designated as my supervisors and/or administrators. Further, I will use in a responsible manner information gained in the course of my service at Visiting Nurse Service. I also certify that the information submitted on this application is true and accurate and I authorize UR Medicine Home Care to verify my references.

Background Check*

I Agree