JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Fourth Coast Companions Volunteer Training
When: November 8, 2023
Time: 9am-3pm (catered lunch provided)
Where: 265 Andrews St. Massena, NY (New Testament Church)
Contact us at (315) 514-9394 info@fourthcoastcompanions.com
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Fourth Coast Companions
Volunteer friendship support program for the greater Massena area to
help elder neighbors age in place more successfully.
Please indicate which Fourth Coast Companions volunteer training session you plan to attend:
*
November 8, 2023
Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Mailing Address:
*
Your answer
Phone Number:
*
Your answer
Email:
*
Your answer
Previous Volunteer Experience:
*
Your answer
Occupation (previous, if retired):
*
Your answer
Why do you want to volunteer with Fourth Coast Companions?
Your answer
Volunteer Preferences
Frequency of volunteer availability:
Daily
Weekly
Semi Weekly
Monthly
Clear selection
I could visit/help more than one person:
Yes
No
Clear selection
I am willing to visit with a smoker:
Yes
No
Clear selection
I am willing to visit with someone who has pets:
Yes
No
Clear selection
Volunteer Assignment Choices
Please select those of interest to you
Friendly home visits
Friendly phone conversations
Transportation to appointments/events
Respite for caregiver (caregiver outings such as shopping, haircut etc)
Assistance with shopping and errands
Assistance with meal preparation
Assistance with correspondence (not bill paying)
Faith-based activities
Crafts
Recreational activities—board games, cards, puzzles, etc.
Gardening
Outings together
Art/music/literature enjoyment
Physical fitness, light exercise
Additional Interests (education, general interests, hobbies, skills, etc.):
Your answer
Other Considerations (such as distance willing to travel):
Your answer
Health Information
Covid-19 and Flu vaccination not required. Information requested for volunteer/elder matching purposes.
Have you been vaccinated for COVID-19?
*
Yes
No
Prefer not to answer
Do you plan to receive vaccination annually for:
COVID-19
*
Yes
No
Prefer not to answer
Flu
*
Yes
No
Prefer not to answer
Do you have any health conditions that make you high risk for COVID-19 or the Flu?
Yes
No
Clear selection
Do you have any health or physical conditions that may limit your activities?
Yes
No
Clear selection
Do you have any dietary restrictions? (Catered lunch provided for the training)
*
None
Vegetarian
Gluten-free
Other:
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
