Payne-Phalen Living at Home/
Block Nurse Program

Volunteer Information Date: ______________

Name: ______________________________________________

Address: __________________________________________________

City: ________________________________ MN Zip Code: __________

Home phone: _________________Work phone: __________________

Cell phone: ____________________ Email: _______________________

Male ________ Female _________ Birth date: __________________

Age group (Check): 19 or under _____ 20-39 _____ 40-59 ____ 60+ ____

Present employer (if employed) _________________________________

Occupation (former, if not working/retired) ________________________

Person to notify in case of emergency:

Name: ____________________________ Relationship: ______________

Address: __________________________ Phone: ___________________

_____________________________________________MN _____________

ADDITIONAL INFORMATION:

1. Which of the following volunteer activities interest you?

_____ Friendly visiting

_____ Respite care

_____ Companion on outings

_____ Shopping assistance

_____ Transportation

______ Household projects

______Board work (fundraising, public relations etc.)

______ Other

______ Yard work

2. What days and times are you available to volunteer?

Times:

Mon _____________

Tues _____________

Wed _____________

Thurs _____________

Fri _____________

Sat _____________

Sun _____________

3. Do you have any physical limitations or health problems that we should know about that may require consideration or special assignments? _________________________________________________________

4. Please list any special skills, hobbies, and interests that could help in matching you with clients: __________________________________________________________

__________________________________________________________

5. Do you presently serve as a volunteer? If so, please give the name of the organization, activity, and schedule.

__________________________________________________________

6. What previous experience/training do you have with seniors? __________________________________________________________

__________________________________________________________

7. If you will provide transportation, please complete the following:

Driver�s license number: _________________________________________________________

Automobile Insurance Company: _________________________________________________________

Automobile Insurance Policy Number: _________________________________________________________

8. How did you find out about our volunteer program?

______Brochure _____Poster _____ Newsletter _____ Church bulletin

________________ Program _____ Website (which one ___________) ____________Other

9. Please list references:

Name: _________________________ Relationship: _______________

Address: _______________________ Phone: ____________________

City: ___________________________MN Zip Code: _______________ Email:____________________________________________________

Name: _________________________ Relationship: _______________

Address: _______________________ Phone: ____________________

City: ___________________________MN Zip Code _______________

I give permission for the Payne-Phalen Living at Home/Block Nurse Program to check the references listed above.

Signature: ___________________________________

Date: _______________________________________

Thank you for taking time to complete this information. Please return the completed form to the Manager of Volunteer Services at the Payne-Phalen Living at Home/Block Nurse Program office. Please call the Manager of Volunteer Services if you have questions.

1280 Arcade St.

St. Paul, MN 55106

651.774.7078 Ext. 24

Fax: 651.774.7599

www.blocknurse.org/payne-phalen

For Office Use Only

Date interviewed __________________________________________

References checked _______________________________________

Client match ______________________________________________

Orientation done by ________________________________________

Volunteer assignment: _____________________________________

_________________________________________________________

Training __________________________________________________


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Our Pages Home About Us News Contact Us Services Volunteer Board Members Calendar of Events FAQ Funders and Donors Photo Gallery Community Partners & Resources Newsletters Links 1280 Arcade St., St Paul, MN 55106 651.774.7078	Payne-Phalen Living at Home/ Block Nurse Program Volunteer Information Date: ______________ Name: ______________________________________________ Address: __________________________________________________ City: ________________________________ MN Zip Code: __________ Home phone: _________________Work phone: __________________ Cell phone: ____________________ Email: _______________________ Male ________ Female _________ Birth date: __________________ Age group (Check): 19 or under _____ 20-39 _____ 40-59 ____ 60+ ____ Present employer (if employed) _________________________________ Occupation (former, if not working/retired) ________________________ Person to notify in case of emergency: Name: ____________________________ Relationship: ______________ Address: __________________________ Phone: ___________________ _____________________________________________MN _____________ ADDITIONAL INFORMATION: 1. Which of the following volunteer activities interest you? _____ Friendly visiting _____ Respite care _____ Companion on outings _____ Shopping assistance _____ Transportation ______ Household projects ______Board work (fundraising, public relations etc.) ______ Other ______ Yard work 2. What days and times are you available to volunteer? Times: Mon _____________ Tues _____________ Wed _____________ Thurs _____________ Fri _____________ Sat _____________ Sun _____________ 3. Do you have any physical limitations or health problems that we should know about that may require consideration or special assignments? _________________________________________________________ 4. Please list any special skills, hobbies, and interests that could help in matching you with clients: __________________________________________________________ __________________________________________________________ 5. Do you presently serve as a volunteer? If so, please give the name of the organization, activity, and schedule. __________________________________________________________ __________________________________________________________ 6. What previous experience/training do you have with seniors? __________________________________________________________ __________________________________________________________ 7. If you will provide transportation, please complete the following: Driver�s license number: _________________________________________________________ Automobile Insurance Company: _________________________________________________________ Automobile Insurance Policy Number: _________________________________________________________ 8. How did you find out about our volunteer program? ______Brochure _____Poster _____ Newsletter _____ Church bulletin ________________ Program _____ Website (which one ___________) ____________Other 9. Please list references: Name: _________________________ Relationship: _______________ Address: _______________________ Phone: ____________________ City: ___________________________MN Zip Code: _______________ Email:____________________________________________________ Name: _________________________ Relationship: _______________ Address: _______________________ Phone: ____________________ City: ___________________________MN Zip Code _______________ I give permission for the Payne-Phalen Living at Home/Block Nurse Program to check the references listed above. Signature: ___________________________________ Date: _______________________________________ Thank you for taking time to complete this information. Please return the completed form to the Manager of Volunteer Services at the Payne-Phalen Living at Home/Block Nurse Program office. Please call the Manager of Volunteer Services if you have questions. 1280 Arcade St. St. Paul, MN 55106 651.774.7078 Ext. 24 Fax: 651.774.7599 www.blocknurse.org/payne-phalen For Office Use Only Date interviewed __________________________________________ References checked _______________________________________ Client match ______________________________________________ Orientation done by ________________________________________ Volunteer assignment: _____________________________________ _________________________________________________________ Training __________________________________________________
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Our Pages

Payne-Phalen Living at Home/Block Nurse Program

Volunteer Information Date: ______________

1280 Arcade St.

St. Paul, MN 55106

651.774.7078 Ext. 24

Fax: 651.774.7599

www.blocknurse.org/payne-phalen

Payne-Phalen Living at Home/
Block Nurse Program