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Volunteer Interest Form

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( ** indicates a required field. )
** First Name	Your preferred first name or nickname
** Last Name	Your last name
** Primary Phone	Your primary (e.g. home) telephone number
Secondary Phone	Secondary (e.g. cell) phone number, if any
Email Address	Your email address
What would you like to do? (Please check all that apply)
Area	Specifics
Transportation	Local (< 25 miles)  Longer Distance  Brief (under 1 hour)  Medium (1-2 hours)  Longer (2-4 hours)  Scheduled  Unscheduled  Wheelchair  Pet transport
Pickup / Delivery	Medicines  Groceries  Meals  Miscellaneous
Personal Support	Daily phone assurance  Visiting  Reading  Correspondence  Hair cutting  Caregiver relief
Household Chores	Meal preparation  Moderate cleaning  Heavy cleaning  House plant care  Pet sitting  Dog walking  Bookkeeping  Computer help  De-cluttering  Downsizing
Home Maintenance	Safety check  Home adaptation  Minor electrical repairs  Other minor repairs  Weeding/landscaping
Group Activities	Lead activities  Teach classes  Assist
SNaP Events	Membership Drive  Pancake Breakfast  Casino Night  Potluck & Book Sale  Pecan Sale  Holiday Bazaar  Other
SNaP Administration	Coordinate volunteers  Telephone calling  Telephone answering  Proofreading  Greeting/sympathy cards  Data entry  Monitor web site
Task Notes    Conditions? Anything else you'd like to do?
What times are good for you? (Please check all that apply)
Available    Times	Sun     Mon     Tue     Wed     Thu     Fri     Sat   Morning Afternoon Evening Overnight
What times are NOT good for you? (Please check all that apply)
UNavailable    Times	Sun     Mon     Tue     Wed     Thu     Fri     Sat   Morning Afternoon Evening Overnight
Availability Notes
** Security Code:	(Enter this number: – prevents bogus entries)

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Fayetteville PA 17222, USA. All rights reserved.

Updated 12/17/10