Volunteer Application


Before you begin filling out the Volunteer Form please read the
Volunteer Policies and confirm that you can abide by these required policies.

* Note: Please fill out all fields to complete the application. All fields are required.

Volunteer Contact Info:

Your Name:



City, State:


Are you a legal resident of the United States:

Your Email:

Phone #:

Emergency Contact Name:

Emergency Contact Phone #:

Skills & Other Questions

Level of education:

Career Occupation:

Languages you speak:

How did you find out about ASSIST:

Please share your reasons for wanting to volunteer with ASSIST:

Do you have any previous work volunteering? Please explain:

What are your interests and/or skills:

Do you have any physical limitations:

Do you have any physical or mental health impairments, including alcohol or drug usage which would affect your ability in terms of skill, attitude, or judgement to perform your volunteer duties?

If yes, please explain:


We are seeking volunteers who can work 2 days per week, for a total of approximately 4 - 5 hours for the week. (The initial two weeks may require more time with the new Care Receivers)

Please select your time preferences on the days you are available
AM = Before Noon
PM = noon - 5p.m.
Any = Available AM or PM
Neither = Not available that day

 AM PM Any Neither
 AM PM Any Neither
 AM PM Any Neither
 AM PM Any Neither
 AM PM Any Neither
 AM PM Any Neither
 AM PM Any Neither

Are you prepared to complete 4 hours of training?
 Yes No
Are you prepared to attend the once a month support meeting?
 Yes No
Does your schedule permit you to attend meetings during the work day?
 Yes No
Can you commit to be an ASSIST volunteer for at least one year?
 Yes No


First Reference:

Reference Name:

Reference Phone:

Reference Email:

Second Reference:

Reference Name:

Reference Phone:

Reference Email:

Third Reference:

Reference Name:

Reference Phone:

Reference Email:

I understand that a background check is required for all potential volunteers and that before becoming a volunteer I will need to provide additional details (social security, date of birth, vehicle model, driver's license #) to ASSIST so that a background check can be performed.
 Yes No