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Family and Elder Application

If you have questions about this for please contact us at 303-830-9035 or michelle@bessieshope.org. Please understand that the Family & Elders program volunteers are expected to make a one year commitment of service in order to promote meaningful relationships with the elders. This will be explained further in orientation.

While we have a huge need for volunteers in this program, it can sometimes take up to a month for final placement because of coordinating schedules, required paperwork, and other factors specific to each facility. However, once you are placed this becomes a very flexible volunteer position and you can visit according to your schedule.

We run CBI background checks on all volunteers before they can begin visiting elders. You can bring a check for $10.00 to your orientation to cover this cost or make the payment online by going to http://bessieshope.org/civicrm/contribute/transact?reset=1&id=10.

Volunteer or Family Name: *

Number of Adult Volunteers: *

Number of Youth Volunteers: *

How often do you intend to visit?:

Primary Phone Number for Volunteer or Family: *

How did you hear about Bessie's Hope?: *

When are the best times for your visits?: *

Please give us an idea of when your group will be able to participate in our program.

Which orientation do you plan to attend?:

Please enter the date of the orientation you plan to attend. Orientation dates can be found at http://bessieshope.org/program/family-elders.

Primary Mailing Address for Family or Individual

Street: *

City: *

State: *

Zip Code: *

Individual or Family Member Name

If you are volunteering as an individual, please enter your contact information here. If you are a family, please enter one of the adult family member's contact information here. If your address information is the same as above you can leave these address fields blank. Thank you!

Date Of Birth: *

First Name: *

Last Name: *

City:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Email Address: *

Place of Employment:

Second Adult Family Member

For families with more than one adult volunteer, please enter the second adult's contact information here. If you are an individual volunteer skip this section.

Date Of Birth:

First Name:

Last Name:

Street Address:

City:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Place of Employment:

Family Members

Below, please enter the names of any children who are volunteering with the family.

First Name:

Last Name:

First Name:

Last Name:

I would prefer to visit with an elder who :

is male

is female

is Higher functioning

is experiencing symptoms of Alzheimer's

Select as many as apply.

Pets:

I would like to take my pet to the elder care community

Specific Interests or Background:

Please describe any specific interests or anything about your background that you would like us to consider when matching you with an elder.

Other Volunteer Interests::

Lead Adult or Youth Group

Dream Team

Administrative

Special Events/Fundraising

Marketing/Public Relations

Please select any other volunteer areas you are interested in.

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