Companion Referral Form

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Address(Required)

Street Address City State ZIP Code

Home Phone Number (include area code)(Required)

Cell Number (include area code)(Required)

1. Do you own a reliable vehicle with adequate auto insurance?(Required)

Yes

2. Do you have experience working with seniors?(Required)

Yes

3. Are you available to be a Senior Companion for at least 5 hours per week?(Required)

Yes

4. What days of the week are you available to volunteer as a Senior Companion?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

5. On the above selected days, what timeframe are you able to volunteer?(Required)

6. Are you willing to allow us to complete a fingerprint-based criminal background check on you?(Required)

Yes

7. Do you smoke?(Required)

Yes

8. Please list any special skills you have and/or hobbies you enjoy:(Required)

9. How did you hear about the Senior Companion Program? (TV, Radio, Newspaper, Word of Mouth, etc.)(Required)

To qualify for the tax-free stipend, you must meet income eligibility requirements. All Senior Companions receive an hourly stipend, mileage reimbursement, paid training, holiday, sick, and vacation time, and are covered by excess supplemental insurance while actively serving.

Become a Volunteer

Volunteering in your community leads to a sense of fulfillment, decreasing stress and promoting a general feeling of well-being. When you volunteer regularly, you gain for yourself as much as you give to others. Click below to find volunteer opportunities that will utilize your skills and talents.

Our Programs

America Reads
Project Warm-up