Volunteer

Note: Volunteers must be age fourteen (14) or older. Minor volunteers, ages 14 – 17, require parental consent (see page 2).

Name: (required)

Address:

How long at the above address ?

If less than 5 years, previous address:

Home phone number:

Cell phone number:

Email: (required)

Employer:

Employer phone number:

Have you ever been convicted of a felony ?
YesNo

If Yes – explain:

How did you learn of our program ?

What position would you like to volunteer for ?
DriverKitchen helperAdministrative helperFuture Board Member

Would you like to volunteer:
DailyWeeklyEvery other weekMonthlySubstitute only

Check the days of the week you will be available:
MondayTuesdayWednesdayThursdayFriday

Are you available throughout the year ?
YesNo
Just from

Do you have any medical condition that would impair your ability to drive or do kitchen duties ?
YesNo
Yes – explain:

For Driver volunteer applicants only:

Car make and model:

License plate number:
?

Driver’s license number:

All applicants: Please list 3 personal or professional references (include address and phone number)

1.

2.

3.

Confidentiality. I hereby understand that any and all information which I may receive regarding any client of ECHO Meals on Wheels (ECHO MOW) is to remain confidential. I hereby agree to not discuss any such client information which I may receive through my volunteer activities with anyone.

Release of Liability. I hereby release ECHO Meals on Wheels West, Inc., from any claim or liability for any injury or illness resulting to any minor or non‐applicant who may accompany a volunteer from time to time during the volunteer’s activities with ECHO MOW, where such injury or illness is not occasioned by any fault or neglect on the part of ECHO MOW.

Certification of Information Provided. I hereby certify that I, the undersigned applicant, have personally completed this application. I declare that the facts contained in this application and any supporting documents are true and complete to the best of my knowledge. I understand that any false information or omission will disqualify me from further consideration for volunteering and if discovered at a later date, will be justification for my dismissal from volunteering.

Applicant Name (print):

Applicant signature:

Date:

CONSENT FOR MINOR UNDER AGE 18 TO PARTICIPATE IN VOLUNTEER ACTIVITIES

I hereby authorize , a minor, to participate in volunteer activities
with ECHO Meals on Wheels West, Inc. as may from time to time be prescribed by the organization. I release ECHO MOW from any claim or liability for any injury or illness resulting to said minor while participating in such volunteer activities not occasioned by any fault or neglect on the part of ECHO MOW. I understand and accept the requirements as set forth in the attached and give my permission and assistance in reinforcing the rules and regulations for the above minor to serve as a volunteer.

Parent or Guardian Name (print)

Parent or Guardian signature:

Date:

5+12=?

ECHO Meals on Wheels West, Inc.

4600 West Genesee Street, Syracuse, NY 13219

(315) 487‐2878