Volunteer Enrollment Form

Step 1 of 5

    Mailing Address (required):

    Home Address (if different from above):




    Gender: MaleFemale



    Do you have auto insurance? YesNo

    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?

    What hours are convenient for you to volunteer?



    I consent to my submitted data being collected and stored.
    (NOTE: This checkbox MUST be checked in order to submit the form.)