Wendy Klinkner (847-­‐869-­‐0682) 535 Custer Avenue -­‐ Evanston, IL 60202 mailto:wendy@senior-­‐connections.org Name ______________________________________________________ Are you a Northwestern student? Indicate YES or NO If yes, when do you expect to graduate (month/year)? _____/______ Your Local Address: Students, please provide your permanent address: Local Telephone (xxx-­‐xxx-­‐xxxx): ____________________________ Cell Phone (xxx-­‐xxx-­‐xxxx): _________________________________ Email Address: ___________________________________________ Birthdate (DD/MM/YYYY) _____/________/_______ Other than English, list any languages you speak fluently. How did you hear about Senior Connections? Check any that apply. ☐ I spoke to a volunteer or Board Member. ☐ Online/Internet Searches ☐ ETHS ☐ Northwestern ☐ I know a senior in your program. ☐ Other (please explain): Please select the choice that best describes your employment situation. ☐ Student ☐ Working F/T or P/T ☐ Retired ☐ Stay at home parent ☐ Other (please explain): What is your primary religious affiliation? ☐ Christianity ☐ Judaism ☐ Islam ☐ Hinduism ☐ Chinese Folk Religion ☐ Buddhism ☐ Sihkism ☐ Atheism ☐ Unaffiliated ☐ Agnosticism
Please list or describe your interests and hobbies. What experience do you have, if any, working with the elderly? What types of activities are comfortable doing with a senior? ☐ Assist with grocery shopping ☐ Reading ☐ Writing ☐ Light chores ☐ Minor repairs (ex: changing a light bulb) ☐ Going for a walk ☐ Going out for coffee ☐ Scrapbooking ☐ Computer work ☐ Driving to a doctor’s appointment ☐ Other (please elaborate): Which best describes the transportation you will use to visit a senior? ☐ I own a car. ☐ I am able to borrow a car. ☐ Walking ☐ Bicycle ☐ Metra or CTA If you own or have use of a car, would you feel comfortable driving a senior to an event or an errand such as a doctor's appointment? (Proof of a valid driver license will be required later.) Choose YES or NO Are you currently under a doctor’s care? Please choose YES or NO If you answered YES, please indicate how your physical or emotional condition will affect your volunteering. Use more space if needed. Do you have a criminal record? Please choose YES or NO If you answered YES, please explain the circumstances. Use more space if needed.
Please include two non-­‐family references. 1) Name of reference: __________________________________________________ Phone Number: ______________________________________________________ How they know you: __________________________________________________ 2) Name of reference: ___________________________________________________ Phone Number: ______________________________________________________ How they know you __________________________________________________ Please include an emergency contact. Contact name: _________________________________________________________ Relationship to you: _____________________________________________________ Phone Number – Cell: ___________________________________________________ Phone Number – Home/Office: ______________________________________ Mail or scan this completed form back to Wendy Klinkner at wendy@senior-­‐
connections.org. Thank very much and we look forward to meeting you! Comments from References: Matched with: Date of Introduction: Arrangements for Meeting: Check when completed: Confirmation calls for introductory visit________Visitor_______Senior _______Data Entry _______E-­‐mail Entry _______References completed _______Training Attended Date of Final Visit or Graduation: