Tender Care Village
(Street, Road, Ave) (City and Zip)
Preferred way for us to contact you:___________ Best time to contact you:_________
Emergency Contact Information:
Reference: Please provide two personal or professional references (not a family member).
Do you have any physical restrictions or limitations?_____________________________________________________________
Do you have any allergies (including pet allergies) that would prevent you from entering
a member’s home? Yes___ No ___
If yes, please explain restrictions:__________________________________________
Do you smoke? Yes___ No___ Will you enter a smoker’s home Yes___ No___
Are you fluent in another language? ________________________________________
Do you have a car? Yes___ No___
If yes, are you willing to drive members? Yes___ No___
I am willing to transport members to: Kennewick___ Richland___ Pasco___
Please indicate what service(s) you would be willing to provide.
___1. Transportation to medical appointments, shopping, errands, etc.
___2. Helping members with their weekly grocery shopping needs.
___3. Handyman services, help doing small home repairs.
___4. Misc. errands for homebound members.
___5. Make calls to check in with members.
___6. Friendly Visitor, check in, help with a hobby, read or visit.
___7. Yard Care, (we are not a lawn care service, but can help with some seasonal
___8. Miscellaneous outdoor/indoor household tasks, changing lightbulbs, changing
smoke detector batteries, hanging pictures, lifting boxes for storage, snow
shoveling, sweeping walkways, etc.
___9. Help members with organizing, reorganizing and downsizing.
___10. Tech Support, PC___ or MAC___. Also, TV remote controls, connecting
___11. Pet Care (temporary need)
___13. Help with Tender Care Village, answering phones, filing, mailing, etc.
___14. Help with Tender Care Village sponsored events and/or fundraisers.
___15. Other – Please describe ____________________________________________
___16. I cannot help right now, but do keep me on your mailing list.
Confidentiality, Liability Waiver and Verified Volunteers Authorization
Please read the following information carefully.
I agree to protect the confidentiality of all information pertaining to any Tender Care Village member, non-member or other volunteer or client associated with Tender Care Village. Your signature below acknowledges your agreement to adhere to this confidentiality policy.
I acknowledge that as a volunteer, I am not an employee of Tender Care Village and understand that I will not be paid for any work I perform. I consent and agree to assume all responsibility for any and all risks or events of damage or injury that may occur during my volunteer work and that I am volunteering at my own risk. I fully and forever release and discharge Tender Care Village, its officers, employees, agents and successors from any loss, cost, damages or other liability which I may incur during my volunteer work. Your signature below acknowledges your acceptance of this liability waiver.
I understand that any person volunteering directly with individuals must undergo a criminal background investigation. This is for the sole purpose of gathering accurate information regarding volunteer services at Tender Care Village and is strictly confidential. If you are willing to provide transportation, Tender Care Village will need a copy of your driver’s license, automobile insurance showing liability coverage and a complete motor vehicles record check from the Department of Motor Vehicles. Your signature below acknowledges that a Verified Volunteers check will be made and if providing transportation, copies of the items listed above will be submitted to the Tender Care Village Director.
Please Print Name______________________________________________________
Please complete and return this form to:
Tender Care Village
3019 Duportail Street #202
Richland, WA 99352