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Senior Application

Senior Application

First Name *
Last Name *
Personal Information
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Are you a U.S. military veteran?
Contact Person In Case of Emergency
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Volunteer Preference
Age
Gender
I give permission to Befrienders, Inc. to use my photograph for promotional use (promoting our program helps us stay in operation - please help us reach out to others in this way).
Permission

Prior to allowing a Befriender volunteer visitor to drive anyone in our program, we require them to provide a valid driver's license, proof of liability insurance, and sign our "Volunteer Driving Agreement," which can be provided to you upon request. Please sign and date below to agree to the following if there is any chance that our Befriender visitor will be driving you anywhere: I knowingly and voluntarily have made a request to allow my Befrienders volunteer visitor (hereafter called Befriender) to drive me in their personal vehicle, and I do so at my own risk. In consideration for permission to allow my Befriender to drive me, I waive and release Befrienders and its affiliates from any and all liability for personal injury, death, and/or damage or loss of my personal property occurring while driving with my Befriender.

Criminal Background Check
Have you ever been arrested or convicted of a criminal offense?

I understand that Befrienders does not routinely conduct criminal background checks on seniors participating in its programs. However, if deemed necessary by Befrienders staff, I agree to undergo a criminal background check to support the safety and well-being of participants and volunteers. I authorize Befrienders and its background screening agent, ClearStar Services, to conduct such a check and release relevant information to Befrienders for program-related purposes.

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