The Carter Burden Center for Aging

Volunteer Application

Complete this application if you are interested in volunteering with the Carter Burden Center. Please do not leave any fields blank. You may also request that an application be emailed, faxed, or mailed to you by contacting Volunteer Services at volunteerservices@burdencntr.org. Thank you.

Name:		Today's Date:
Address:		Apt.#:
City:		State:
Zip Code:		Email:
Home Phone:		Work Phone:
Date of Birth:		Gender

With which program(s) are you interested in volunteering?
Friendly Visiting	Grocery Shopping	Medical Escorting
Telefriend	Weekday Meal Service	Senior Program
Computer Training	Saturday Meals-on-Heels	Young Professionals Group
How did you hear about us?

Please describe the senior with whom you would like to work:
Interests/Hobbies (include something you may want to share with a senior):
Languages spoken other than English:
Days and Times you are available:
Do you have any allergies or conditions that would hinder a home visit?
Is there anything else you think we should know?

If currently enrolled in school:

Name of School:
Current Year:
Major:

Present Employer:
Position:
Previous Employment:
Volunteer Experience:

Emergency Contact:
Relationship:
Phone:

References (at least one professional; students include advisor)

Reference One		Reference Two
Name:		Name:
Relationship:		Relationship:
Phone:		Phone:

The above information is true and correct. I understand that I represent the integrity of the Carter Burden Center for the Aging, and through their Volunteer Program (VSEY), will adhere to the policies of the program as I serve as a volunteer.

I agree

Email us about volunteering