Become a Mercy Care Volunteer

Date

First Name *

Last Name *

Mailing Address *

County that you live in?EssexFranklin

Phone *

Email *

Birthdate *

Occupation (past if retired)

Previous Volunteer Experience

How did you hear about Mercy Care? *

Why do you want to volunteer with Mercy Care? *

Frequency of volunteer availability:MonthlySemi-WeeklyWeeklyDaily

I could visit/help more than one personYesNo

I am willing to visit with a smoker YesNo

I am willing to visit with someone who has pets.YesNo

I am willing to visit with someone who has not been vaccinated for COVID-19YesNo

General interests, hobbies and skills

Do you speak any other languages?YesNo

If yes, what language(s)?

Volunteer Assignment Choices

Please check those of interest to you

Friendly home visits

Friendly phone conversations

Transportation (your car) to appointments/events

Respite for Caregiver

Assistance with shopping and errands

Assistance with meal preparation

Assistance with light housekeeping

Assistance with technology

Recreational activities - board games, cards, crafts, puzzles

Gardening

Outings together

Art, music, literature

Physical fitness, walks, light exercise

Faith-based activities

Additional interests: Please describe here:

Other Considerations (such as distance willing to travel):

Health Information

Do you have any health or physical conditions that may limit your activities?YesNo

If yes, please describe:

Do you have any dietary restrictions? (Used for catered lunch during Training)NoneVegetarianGluten freeOther

COVID-19 and flu vaccination not required. Information requested for volunteer / elder matching purposes.

Have you been vaccinated for COVID-19?YesNoPrefer not to answer

Do you plan to receive vaccination annually for:

COVID-19YesNoPrefer not to answer

FluYesNoPrefer not to answer

Please provide two personal references to be contacted following completion of Friendship Volunteer Training.

Name, Relationship, Phone Number, Email, Preferred method of contact