Volunteer Registration

Please complete questionnaire. If a question does not pertain to you, indicate N/A (not applicable). Return completed form by clicking on Submit button at bottom of the form. If you are unable to read or submit this form, please participate by contacting us via e-mail seniors@ci.berkeley.ca.us, or telephone (510) 981-5200, or TDD (510) 981-6903.

Name:

Address:

City: Zip:

Phone:

E-Mail:

CA State License No: Expiration Date:

Car Insurance (for Meals on Wheels meal delivery only):

Applicable Experience?

What do you want to do as a volunteer?

At which center will you be volunteering?

North Berkeley

South Berkeley

West Berkeley

Meals on Wheels

Which days of the week you can volunteer to us?

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Time? From to

Date beginning? until

How did you learn about the Division on Aging?

Friend/Family

Staff

Newspaper

Public Service Announcement

Website:

Other:

Emergency contact/phone:

Required licenses must be confirmed by the Volunteer's Supervisor. This form must be approved by the requesting official and the department representative who will then forward to personnel.