Senior Circle - Friendship Circle of Virginia

Name*

First Last

All volunteers must be 18+

Phone (Cell)*

Email*

DOB*

Address*

Street Address City State ZIP Code

Preferred Pronouns

Religion

Languages Spoken (primary first)*

How did you hear about Senior Circle?*

What special skills, interests, or hobbies do you have?

Please list any relevant experience you have.

How often are you available to volunteer?*

Which day(s) are you available? Check all that apply.*

What time of day are you available to volunteer? Check all that apply.

Morning
Mid-day
Afternoon
Evening

What is your main form of transportation?*

Volunteer's Recent Photo*

Accepted file types: jpg, png, gif, Max. file size: 250 MB.

Preferred Communication Method (check all that apply)*

Text
Email
Phone Call
Whatsapp

Do you have a medical condition that would impact your volunteer experience*

Yes
No

Do you have a friend who is interested in visiting with a senior?*

Yes
No

Friend's Name

Friend's Phone

Friend's Email

1. *Confidentiality & Privacy* I will keep all personal and health-related information about my Senior Circle match confidential, in accordance with the *federal HIPAA Privacy Rule* and Friendship Circle’s policies. 2. *Commitment & Communication* I understand that *Senior Circle is a commitment, and I will give my best effort to maintain my scheduled weekly visits. If I am unable to attend a visit, I will inform the **Friendship Circle staff in a timely manner*. 3. *Representation & Conduct* I will represent *Friendship Circle of Virginia* with respect, kindness, and integrity, ensuring that my interactions with my Senior Circle match foster a positive and meaningful experience. 4. *Safety & Incident Reporting* If an injury, emergency, or other concerning incident occurs during my visit, I will report it to *Friendship Circle staff as soon as possible*. 5. *Liability & Release* I understand that *Friendship Circle of Virginia is independently owned, operated, and controlled. I release **Friendship Circle, its employees, directors, officers, volunteers, affiliates, and all associated organizations* from any and all claims or liability arising from my participation in the Senior Circle program. By participating in *Senior Circle*, I acknowledge and agree to abide by this Code of Conduct.

I agree to follow the Friendship Circle of Virginia's Code of Conduct.*

I agree

Signature*

Phone

This field is for validation purposes and should be left unchanged.