Volunteer Enrollment Form Step 1 of 5 Name: Mailing Address (required): (Street) (City) (Zip Code) Home Address (if different from above): (Street) (City) (Zip Code) Home Phone: Work Phone: Cell Phone: Email Address: Birthdate: Gender: MaleFemale Emergency Contact: Emergency Contact Phone: Relationship to You: Your Interests/Skills: What other languages do you speak? Do you have auto insurance? YesNo Auto Insurance Policy #: 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 How many days a week can you volunteer? What hours are convenient for you to volunteer? Start Time: End Time: How did you hear about Na Hoaloha? Notes: I consent to my submitted data being collected and stored. (NOTE: This checkbox MUST be checked in order to submit the form.)