Volunteer Enrollment Form

Step 1 of 5

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?

What hours are convenient for you to volunteer?



I consent to my submitted data being collected and stored.
(NOTE: This checkbox MUST be checked in order to submit the form.)