Personal Information


I prefer to be contacted by


How often and for how long a period of time are you available to volunteer? (Check all that apply)

Check areas of interest


Please list two references. Do not list family members.

In case of emergency


Background Check

Have you ever been convicted of any crime, including sex related or child abuse related offenses, in any state or country?

If yes, please explain

Medical Information

As a Chai4ever Volunteer, you may work in a health care environment and/or come into contact immunosuppressed adults or children.

Do you have any physical or medical conditions and/or limitations that would preclude you from Volunteering in any circumstance either in the home or in a Health Care setting (such as a hospital or nursing home)?

if yes, please explain

Consent and Release

I voluntarily consent to and authorize Chai4ever and/or their assigned agents or consumer reporting agencies to request and receive any consumer reports, investigative reports, or information, including law enforcement records, criminal records, DMV records, civil records, employment verifications, eviction searches, and/or consumer credit reports.

I authorize any persons, companies, corporations, consumer reporting agencies, courts of law current or past, or employer/s to furnish Chai4ever and/or their assigned agents, associates or consumer reporting agencies with any or all information requested about me. I further agree to release Chai4ever and/or their assigned agents, associates or consumer reporting agencies, and all persons and organizations providing information from any and all claims, liability, and responsibility arising out of the release of such information arising from these queries. I understand that I have specific prescribed rights as a consumer under the federal fair credit reporting act (FCRA) and may have additional rights under relevant, specific state laws.

I certify that all of the information provided herein is true and accurate. I further agree that in the event any information changes, I will immediately notify Chai4ever of any change. I consent that any falsification of information herein shall be grounds for immediate termination of volunteer status.

Agreement of confidentiality

As a volunteer of Chai4ever, I,, understand that in the course of my contact with Chai4ever families, I might learn privileged and confidential information. Examples of such information might be, but are not limited to, medical conditions and treatment, finances, living arrangements, employment, and/or relationships among family members. I agree to treat as confidential all information about clients or former clients and their families that I learn during the performance of my duties as volunteer. I understand that it would be a violation of policy to disclose such information to anyone other than the executive vice president or director of volunteer services of Chai4ever and that any unauthorized disclosures are considered grounds for immediate termination of volunteer status.

Transportation Assistance Form

Required for all volunteers who will be providing transportation assistance

Have you been involved in any accidents in the last three years?
If yes, please explain

Have you had any moving violations in the last three years?
If yes, please explain

Please attach copies of the following documents:

Chai4ever is required to retain all information on drivers' records for insurance purposes. This document will be used to obtain information from the department of motor vehicles. Please notify Chai4ever of any changes in status, vehicle registration and/or insurance.

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