Support PCA Senior Companion Program Volunteer Application Senior Companion Program 642 N. Broad Street Philadelphia, PA 19130 215-765-9000 Ext. 5124 seniorcp@pcacares.org *Denotes required field Personal Information Name* Mailing Address* City* State* SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code* Telephone* Date of Birth* Age* Sex* SelectFemaleMale Language Spoken* SelectAlbanianArabicArmenianBhili (India)Cambodian, Mon-KhmerChinese, Cantonese, Min, YuehChinese, MandarinDutch, Flemish, BelgianEnglishFarsi(Persian)Filipino, TagalogFrenchFrench, Haitian or Jamaican CreoleGaelic (Ireland)GermanGreekGujaratiHebrew, IsraeliHindiHungarian / MagyarItalianJapaneseKoreanKru (Malaysia)LaotianLithuanianMalayalam (India)Mande (Africa)MongolianNepaleseOtherPolishPortugueseRumanianRussianSerbianSignSpanishThaiTurkishUkranianUnable to CommunicateUrdu (India)VietnameseYiddish Have you ever assisted people who are elderly, sick or homebound? Previous work experience and volunteer experience? How did you find out about the Senior Companion Program? Why do you feel you would be a successful Senior Companion? List your hobbies and special interests: Are you willing to visit homes?YesNo Do you have any physical condition or disability that may affect your ability to serve as a Senior Companion?NoYes What is your primary means of transportation?SelectPersonal CarSEPTACCT ConnectOther Are you available to volunteer 20 hours per week? YesNo Check One: SingleMarried Have you ever been convicted of a crime? NoYes Are you a Veteran? NoYes Other Comments or information you would like to add: Please List References: Name Telephone Name Telephone Name Telephone All of the above information is Correct? Yes
English
Arabic
Chinese (Simplified)
Chinese (Traditional)
French
Gujarati
Haitian Creole
Hindi
Khmer
Korean
Malayalam
Polish
Russian
Spanish
Vietnamese