Volunteer Enrollment Form


 
Mailing Address (required):



 
Home Address (if different from above):



 



 

 

 
Gender: MaleFemale
 



 

 

 
Do you have auto insurance? YesNo

 
What type of vehicle do you have? SedanSmall SUVLarge SUVTruck
 
Are you willing to visit a smoker? YesNo
Are you willing to visit/drive a member of the opposite sex? YesNo
 
In which areas are you willing to volunteer? (Check all that apply)
UpcountryWailuku/KahuluiPaia/HaikuLahainaSouth MauiHanaMolokaiLanai
 
Volunteer Assignment Choices (check all that you are willing to do):
Friendly VisitRespite Care (relief for a family caregiver)TransportationTelephone CallsReading/Letter WritingFundraising AssistanceMinor Home RepairsYard Work/GardeningShopping/ErrandsGoing For WalksBills/Record KeepingHelping In Our Office
 
Which days are you available to volunteer?
SundayMondayTuesdayWednesdayThursdayFridaySaturday
 

 
What hours are convenient for you to volunteer?


 

 

 
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(NOTE: This checkbox MUST be checked in order to submit the form.)