Name

Email address

Address (physical)

Address (mailing)

Phone number

Do you have... Do you have... a valid driver's license? access to a vehicle?

What services are you interest in helping with? (check all that apply) What services are you interest in helping with? (check all that apply)

Volunteer Positions Volunteer Positions Driver/Escort (medical) - Local *gas/maintenance compensation* Driver/Escort (medical) - Winnipeg *gas/maintenance compensation* Shopping/Errands *gas/maintenance compensation* Meals on Wheels Delivery Friendly Visiting Telecheck (telephone buddy) Lifeline Volunteer Board Member

Fee-for-service (casual paid jobs) Fee-for-service (casual paid jobs) Yard Work (Winter and/or summer) General Housekeeping Odd Jobs

What is your availability? What is your availability? Monday Tuesday Wednesday Thursday Friday

Driver’s License Information (for volunteer drivers) Driver’s License Information (for volunteer drivers)

Do you have a valid Manitoba Driver’s License? Do you have a valid Manitoba Driver’s License? YES NO

Do you have access to a vehicle? Do you have access to a vehicle? YES NO

Driver's License #

Autopac (level of liability insurance)

Make, model & color of vehicle (s)

Do you have any health concerns that would limit your ability to assist a client? Do you have any health concerns that would limit your ability to assist a client? YES NO

If yes, please explain

Are you able to push a wheelchair? Are you able to push a wheelchair? YES NO

Are you able to lift a wheelchair? Are you able to lift a wheelchair? YES NO

Can you lift a walker in and out of vehicle? Can you lift a walker in and out of vehicle? YES NO

Other information (skills, hobbies, interests)

How did you hear about our program?

References: Name and Phone Number (2 Required)

Oath of Confidentiality Oath of Confidentiality By checking this box, I agree that I will respect the individuality and privacy of the person I am working for and will keep any conversations and observations confidential. Any concerns that I have regarding the client will be relayed to the South Interlake Seniors Resource Coordinators who will take the appropriate action.