City of East Providence - Volunteer Intake Form

Thank you for your interest in volunteering in your community during the COVID-19 crisis. Please fill out this form and hit "submit" at the end. Our volunteer manager will follow up with you about scheduling.

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* 1. Please fill out your Name and Contact Information:

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number *

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* 2. What is your date of birth?

Volunteers must be at least 18 years old

Date

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* 3. What days/times are you generally available?

	Sundays	Mondays	Tuesdays	Wednesdays	Thursdays	Fridays	Saturdays
Morning	Morning Sundays	Morning Mondays	Morning Tuesdays	Morning Wednesdays	Morning Thursdays	Morning Fridays	Morning Saturdays
Afternoon	Afternoon Sundays	Afternoon Mondays	Afternoon Tuesdays	Afternoon Wednesdays	Afternoon Thursdays	Afternoon Fridays	Afternoon Saturdays
Evening	Evening Sundays	Evening Mondays	Evening Tuesdays	Evening Wednesdays	Evening Thursdays	Evening Fridays	Evening Saturdays

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* 4. Is there anything else we should know about your availability for scheduling purposes?

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* 5. What role(s) are you interested in volunteering for? (Check all that apply - other opportunities may come up as well)

Food shopping

Food pantry

Driver/delivery

Senior Center services

Library services

Animal Shelter

Other (please specify)

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* 6. Are you willing to deliver meals to the elderly?

Yes

Maybe

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* 7. If you are interested in delivering meals to the elderly, do you have a valid driver's license AND access to a vehicle?

Yes, I have a license and a vehicle

No, I don't have a license and/or a vehicle

NA / I cannot deliver meals

The city is currently operating a COVID-19 testing site as well as COVID-19 vaccine clinics at the East Providence Senior Center located at 610 Waterman Ave. We are seeking volunteer healthcare workers including EMTs, nurses, LPNs and physicians, as well as general volunteers who are able to help with non-medical tasks.

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* 8. Are you interested in volunteering at the COVID 19 testing site and/or COVID 19 vaccine clinic?

Yes

Maybe

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* 9. Please list any skills or experience you have that may be helpful for volunteering (i.e. computer skills, food handling, childcare, elder care, truck driving/delivery, nurse, LPN, physician, EMT, etc.):

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* 10. Why do you want to volunteer in the community?

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* 11. How did you hear about this volunteer opportunity?

Social media (Facebook/Instagram/Twitter)

Website

Friend or family member

Coworker

Other (please specify)

Hold Harmless and Release Agreement:

I agree to release, indemnify and hold harmless the City of East Providence and its officers, agents, employees, and representatives from and against all losses, damages, suits, claims, costs, and charges which any person or corporation may directly or indirectly suffer as a result of my participation as a volunteer in any program, activity or event conducted or sanctioned by said City of East Providence. This Hold Harmless and Release Agreement shall be considered a complete and total waiver of any and all liability on the part of the City of East Providence, its servants, agents, or employees and particularly officers and employees of the City of East Providence engaged in the supervision and control of such activities.

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* 12. I give the City of East Providence permission to conduct a background check on me:

Yes, I agree

No, I do not agree

City of East Providence - Volunteer Intake Form

Question Title

* 1. Please fill out your Name and Contact Information:

Question Title

* 2. What is your date of birth?

Question Title

* 3. What days/times are you generally available?

Question Title

* 4. Is there anything else we should know about your availability for scheduling purposes?

Question Title

* 5. What role(s) are you interested in volunteering for? (Check all that apply - other opportunities may come up as well)

Question Title

* 6. Are you willing to deliver meals to the elderly?

Question Title

* 7. If you are interested in delivering meals to the elderly, do you have a valid driver's license AND access to a vehicle?

Question Title

* 8. Are you interested in volunteering at the COVID 19 testing site and/or COVID 19 vaccine clinic?

Question Title

* 9. Please list any skills or experience you have that may be helpful for volunteering (i.e. computer skills, food handling, childcare, elder care, truck driving/delivery, nurse, LPN, physician, EMT, etc.):

Question Title

* 10. Why do you want to volunteer in the community?

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* 11. How did you hear about this volunteer opportunity?

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* 12. I give the City of East Providence permission to conduct a background check on me:

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* 13. If you have a valid and current driver's license, what state is it from? (For background check purposes):

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* 14. Driver's license ID number (for background check purposes):

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* 15. Electronic signature of volunteer (type your first and last name):