| Name: |
|
| Phone Number: |
|
| Email Address: |
|
| Gender: |
Male
Female
|
| Address: |
|
| Student ID #: |
|
| Name of College/ University you are
attending: |
|
| Current Program Enrolled In:
|
|
|
Full
Time
Part
Time
Other
|
| Do you have a current criminal
record check? (A criminal record check is a definate asset, but is not
required at this time). |
|
| What kind of work would you willing
to do for a senior? |
Light Housework
Shopping
Laundry
Pet Care
Gardening
Yard
Work
Odd Jobs
Computer Help
Reading Aloud
Other
|
| Skills that you feel would be useful
to this job: |
|
| Training certificates/licenses you
hold: |
|
| Languages Spoken: |
|
| What days and hours are you
available to work? |
|
| How long are you able to commit to
this program? |
|
| Other Information you feel would be
useful: |
|
| |