Community and Elders Program Application

Group Name*

Address*

Primary Mailing Address for Group

Street Address City State ZIP Code

Primary Phone Number for Group*

How did you hear about Bessie's Hope?*

How often does your group intend to visit?*

When are the best times for your visits?*

Please have each volunteer complete this waiver and release.

Primary Group Leader

Name*

First Last

Address*

Street Address Address Line 2 City State

Home Phone

Cell Phone

Email*

Second Group Leader

Name

First Last

Address

Street Address Address Line 2 City State

Home Phone

Cell Phone

Email

Third Group Leader

Name

First Last

Address

Street Address Address Line 2 City State

Home Phone

Cell Phone

Email

Group Demographics

Please estimate the demographics of your group. This information is important for some of the grants that help Bessie's Hope exist. Skip this if your group does not have youth involved.

Number of Adult Volunteers*

Number of Youth Volunteers*

Please estimate the demographics of the youth from your group. This information is important for some of the grants that help Bessie's Hope exist. Skip this if your group does not have youth involved.

Age Range of Youth

Number of Male Youth Volunteers

Number of Female Youth Volunteers

Number of Youth Volunteers from Low Income Backgrounds

Number of African American Youth Volunteers

Number of Asian Youth Volunteers

Number of Caucasian Youth Volunteers

Number of Hispanic Youth Volunteers

Number of Native American Youth Volunteers

Number of Other