Volunteer Application

Full Name *
Full Name
Legal name as indicated on your Driver's License
Birthdate *
Birthdate
I identify my gender as *
Address *
Address
How Long Have You Have Lived at this Address *
How Long Have You Have Lived at this Address
Month/Year
Cell Phone Number *
Cell Phone Number
Home Phone Number
Home Phone Number
Driving and Vehicle Information
Driver's License Expiration *
Driver's License Expiration
Auto Insurance Expiration Date *
Auto Insurance Expiration Date
Where was your plate issued?
License Plate Expiration Date *
License Plate Expiration Date
Volunteer Interests
Meal Delivery
Shopping Assistance
Friendly Visiting
Office Assistance
Shifts are from 10 am to 2 pm M–F
Your Availability *
Meal delivery routes begin between 11–11:30 am and take about 2 hours to complete. Please mark the all days you are available.
May we contact you for last minute driver requests?
How often would you like to volunteer *
Emergency Contact
Emergency Contact *
Emergency Contact
Emergency Contact Address *
Emergency Contact Address
Emergency Contact Phone *
Emergency Contact Phone
Work Experience
Please list the names and addresses of your most recent or current employers. If none, leave blank.
Please list your: Company name, address, phone number, dates employed and job title/duties.
Please list your: Company name, address, phone number, dates employed and job title/duties.
Please list your: Company name, address, phone number, dates employed and job title/duties.
If yes, please identify the agency/organization and the type of activity you did
I am a Veteran of the United States military or spouse of a Veteran. *
Additional Questions
Language & Other Skills
Please list any physical or medical limitations, education, skills, general interests, hobbies, etc.)
Background Information Disclosure
Please answer the following questions as completely and accurately as possible. Answering affirmatively to any questions will not necessarily bar you from volunteering with Meals at Home. However, failure to comply with these requirements, or providing false information, will likely result in denial or termination of volunteer activities.
Name as it appears on Driver's License or State Issued ID *
Name as it appears on Driver's License or State Issued ID
Do you have criminal charges pending against you or were you ever convicted of any crime (not including traffic violations) anywhere, including federal, state, local, military and tribal courts? *
If yes, list each charge, when it occurred and the city and state where the court is located. You may be asked to supply additional information including certified copy of the judgment of conviction, a copy of the criminal complaint, or any other relevant court or police documents.
Have you ever been convicted of a felony? *
If yes, list each charge, when it occurred and the city and state where the court is located.
Has any government regulatory agency (other than police) ever found that you abused or neglected any person or client?
Please explain, including when and where it happened.
BACKGROUND CHECK AUTHORIZATION/CERTIFICATION *
I submit that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information will result in denial or termination of volunteer activities, and other penalties as provided under the law.
VOLUNTEER AGREEMENT AUTHORIZATION *
Thank you for applying to be a volunteer with Meals on Wheels Northeastern Illinois. Please read and agree to the following: 1) Please note that, if your application is accepted, you will be a volunteer and not an employee of Meals on Wheels Northeastern Illinois. 2) A background investigation will be conducted to evaluate your qualifications for working independently with receivers of service from Meals on Wheels Northeastern Illinois. 3) I authorize the release of information to Meals on Wheels Northeastern Illinois related to my potential volunteer responsibilities and I release all parties from any liability resulting from the release of such information. 4) CONFIDENTIALITY: It is imperative that all information regarding Meals on Wheels Northeastern Illinois service receivers is treated with the utmost confidence and such information may only be released to anyone (including family members) with proper authorization. These restrictions include all types of communication: verbal, written and electronic, including social media. 5) I agree to abide by all Meals on Wheels Northeastern Illinois Volunteer Policies and Procedures during my participation as a Meals on Wheels Northeastern Illinois volunteer. Participation as a Meals on Wheels Northeastern Illinois volunteer may be terminated at any time due to failure to comply with Meals on Wheels Northeastern Illinois policies and procedures. 6) I release Meals on Wheels Northeastern Illinois, it employees, agents, volunteers, donors and sponsors from any and all claims resulting from my participation as a volunteer with Meals on Wheels Northeastern Illinois. 7) AUTHORIZATION/CERTIFICATION I authorize Meals on Wheels Northeastern Illinois to conduct an investigation to determine whether I have ever been charged with a crime and, if so, the disposition of those charges. I authorize Meals on Wheels Northeastern Illinois to request information and assistance from the U.S. Justice Department and the Illinois Department of Law Enforcement in the conduct of this investigation. I authorize Meals on Wheels Northeastern Illinois to request and obtain my Motor Vehicle Record. I understand that information obtained as a result of my authorizing this investigation is confidential. I further certify that the information provided on this form is true and correct. I acknowledge that falsification of any information provided above and/or the results of the background check may be full and sufficient grounds to deny the application or may result in the termination of my volunteer position.
Parental Permission
Applicants under 18 are required to have a parent/legal guardian permission to volunteer with Meals on Wheels Northeastern Illinois.
Name of your parent/legal guardian
Name of your parent/legal guardian
Parent/Legal Guardian Agreement
I (Parent/Guardian) agree that (Applicant) may participate as a volunteer with Meals on Wheels Northeastern Illinois according to the terms of this Volunteer Agreement.