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2. 
4. YPDSS Friendly Visitors Volunteer Application

   Thank you for your interest in becoming a YPDSS Friendly Visitor Volunteer!  

   Are you an energetic person?  Do you enjoy playing board games, walking and chatting with a friend?

   We would love to have you join our team of community volunteers!

   Please fill out this form as completely and accurately as possible.  Thank you.

6. Personal Information
8. Full Name*
9. DOB*
11. Street Address*
13. City*
14. State*
15. Zip Code*
17. Home Phone*
18. Cell Phone*
20. E-mail*
22. Days of the week/month you are available*
24. Hours you are available*

    The visits will only take place during day time (office)  hours of 8 am - 4 pm.

26. Please list specific safety skills you may have (CPR/AED/First Aid/General Safety Training etc.) *
28. Please list your interests and hobbies you would like to share >*
32. Please be sure to answer each of the following >
34. Please check all that apply to you and your personal circumstance. Are you able to:*

    1. Climb flights of stairs
    2. Travel 5 to 10 miles from home
    3. Travel 10 to 20 miles from home

    1. Enter a house with pets (cat/dog)
    2. Enter a house with a smoker
    3. Enter a house and visit while wearing a mask
36. Are you a veteran?*

    1. Yes
    2. No
38. Do you hold a valid VA Driver's License?*

    1. Yes
    2. No
40. Do you wish to receive credit for your volunteer hours?*

    1. Yes
    2. No
42. Do you have any special needs we need to be aware of? If none - please enter N/A.*
44. Please share anything else you would like us to know...
46. Emergency Contact
48. Full Name of Contact*
49. Relationship to you*
51. Street Address*
53. City*
54. State*
55. Zip Code*
57. Cell Phone*
58. Work Phone*
59. Home Phone*
61. Signature Section
63. How did you learn about this volunteer program?*
65. By my signature, I am verifying that I am 18 years of age or older and would like to become a YPDSS Volunteer. *
66. Date (Please enter today's date.)*
    Date (Please enter today's date.)
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field