Become a Mercy Care Volunteer

Friendship Volunteer

Health Care Companion Volunteer

Spiritual Care Companion Volunteer

Parish Nurse Volunteer

Date

First Name *

Last Name *

Mailing Address *

County that you live in?EssexFranklin

Phone *

Email *

Birthdate *

Language Spoken *

Occupation (past if retired)

Previous Volunteer Experience

How did you hear about Mercy Care? *

Why do you want to volunteer with Mercy Care? *

Frequency of volunteer availability:MonthlySemi-WeeklyWeeklyDaily

I could visit/help more than one personYesNo

I am willing to visit with a smoker YesNo

I am willing to visit with someone who has pets.YesNo

I am willing to visit with someone who has not been vaccinated for COVID-19YesNo

Volunteer assignment choices that Interest you

Friendly home visit

Friendly phone conversation

Transportation to appointments/events

Respite for caregiver

Assistance with shopping and errands

Assistance with meal preparation

Assistance with light housekeeping

Assistance with technology

Crafts

Recreational activities-board games, cards, puzzles, etc.

Gardening

Outings together

Art/music/literature enjoyment

Physical fitness, light exercise

Faith-based activites

Additional Interests (education, general interests, hobbies, skills, languages spoken, etc)

Other considerations (such as distance willing to travel)

Health Information

COVID-19 and flu vaccination not required. Information requested for volunteer / elder matching purposes.

Have you been vaccinated for COVID-19?YesNoPrefer not to answer

Do you plan to receive vaccination annually for:

COVID-19YesNoPrefer not to answer

FluYesNoPrefer not to answer

Do you have any health or physical conditions that may limit your activities?YesNo

If yes, please describe

Do you have any dietary restrictions? (Used for catered lunch during Training)NoneVegetarianGluten freeOther

Please provide two personal references to be contacted following completion of Friendship Volunteer Training.

Name, Relationship, Phone Number, Email, Preferred method of contact