Volunteer Enrollment Form

Name:
 
Mailing Address (required):
(Street)
(City)
(Zip Code)
 
Home Address (if different from above):
(Street)
(City)
(Zip Code)
 
Home Phone:
Work Phone:
Cell Phone:
 
Email Address:
 
Birthdate:
 
Gender: MaleFemale
 
Emergency Contact:
Emergency Contact Phone:
Relationship to You:
 
Your Interests/Skills:

 
What other languages do you speak?
 
Do you have auto insurance? YesNo
Auto Insurance Policy #:
 
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?
SundayMondayTuesdayWednesdayThursdayFridaySaturday
 
How many days a week can you volunteer?
 
What hours are convenient for you to volunteer?
Start Time:
End Time:
 
How did you hear about Na Hoaloha?
 
Notes:

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