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2. Senior Companion Program Volunteer Enrollment Form
4. Salutation

   1. Mr.
   2. Mrs.

   1. Ms.
   2. Dr.

   1. Other
5. Salutation - Other
7. First Name
8. Last Name
10. I prefer to be called
12. Address
14. City
15. State
16. Zip Code
18. Home Phone
19. Cell Phone
21. Email
25. Alternate Address

    1. I have another residence and am typically away...
26. From
    From
27. To
    To
29. Address
31. City
32. State
33. Zip Code
37. Demographics
40. Date of Birth
    Date of Birth
41. As of today, I am age 55 or older

    1. Yes
    2. No
43. Gender

    1. Male
    2. Female
45. Military Experience

    1. I served in the armed forces
    2. I am the spouse/widow of a veteran
46. Highest Level of Education

    1. BA/BS
    2. Doctorate
    3. GED
    4. Grade School

    1. High School
    2. Masters
    3. Associates or Some College
    4. Prefer not to answer
48. Are you Bi-Lingual?

    1. Yes
    2. No
49. If yes, what languages do you speak?
51. Do you consider yourself disabled?

    1. Yes
    2. No
52. If yes, please describe your disability.
54. Accomodations:

    We provide reasonable accommodations for individuals with permanent and temporary disabilities as well as varying levels of English proficiency. If you require special arrangements, please specify your needs when making a request.

55. Accommodations Needed

    1. Yes
59. Certifications:

    I hereby state that I offer my services as a volunteer for the Steuben County Office for the Aging (SCOFA) and RSVP. I understand that I am not an employee of the SCOFA, the RSVP project, Steuben County Government, the volunteer station managing my assignment or the Federal Government. I agree to serve without compensation. 

    I understand that my application may be shared with partnered agencies to coordinate volunteer assignments. Some agencies may require a separate volunteer application. The agency may request background checks and may have other volunteer onboarding requirements that they will inform me of before my volunteer service may begin. I understand that no background checks will be performed without my prior consent or knowledge. Other conditions about my volunteer service will apply, such as personal vehicle use, confidentiality agreements, expense reimbursement, and others. These conditions will be reviewed with me in full during my assignment orientation.  

    SCOFA is an equal opportunity agency. Enrollment is without regard to race, color, religion, national origin, sex, age, or disability. Reasonable accommodations will be provided for known limitations of individuals in compliance with the Americans with Disabilities Act. For accommodation information, or if you need special accommodations to complete the application process, please contact the staff at SCOFA and RSVP at 607-664-2298 for assistance.

61. Volunteer's Signature

    Please enter your name to sign the above Certifications

62. Date
    Date
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field