Volunteer Form

Bikur Cholim Needs You!!
Urgent Call for Volunteers

There are many sick and elderly in our community who need YOUR HELP. They need your smile, your warmth, your compassion and your assistance. Please give a little of your precious time to do a great Mitzvah.

Please fill in the information below:

Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Email*
Age*
Volunteer Opportunities (Check all that apply):
- Visits to Nursing Homes and/or Assisted Living Facilities
- Home Visitations
- Hospital Visits (please be advised that volunteers who regularly visit Memorial hospital are required by the hospital to get an annual Flu Shot and PPD (Tuberculin skin) test. Volunteers at the hospital are also subject to a background check and volunteer training done by the hospital). These restrictions do not apply to one time visitors or if you are going to visit a specific patient.
- Telephone Reassurance Phone Calls
- Meal preparation / meal sponsorship
- Other
List Other Volunteer Opportunities*
Days Available to volunteer:*
Best times available to volunteer:*
Languages, skills, hobbies:
Education Completed:
School:
Prior Volunteer or Work Experience:
IN CASE OF EMERGENCY, NOTIFY: (Must be a relative)
Name*
First Last
Relationship:*
Phone (Day)*
Phone (Evening)
MEDICAL INFORMATION:
List Physical Limitations
References
List two references not related to you whom you have know one year or longer:
Reference #1 Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Reference #2 Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Referred to Bikur Cholim by:
Why do you wish to be a Bikur Cholim volunteer?
Electronic Signature*
- By checking this box, I hereby certify that the information I have written on this application is true and correct and that misrepresentation or omission of facts is cause for dismissal. I understand that upon registering for volunteer services with Bikur Cholim I will be subject to an interview and placement by the Volunteer Services Department in a position mutually agreed upon by both parties. I am of good moral character and wish to help others. I understand that any volunteer can be terminated for just cause at any time.

IN CASE OF EMERGENCY, NOTIFY: (Must be a relative)

MEDICAL INFORMATION:

References