Cleveland Foster Grandparent Program

Volunteer Application

 

 

Foster Grandparent Program

2749 Woodhill Rd.     Cleveland, OH 44104                 216-791-9378     

 FAX:  216-791-9754

 

    (Please print)                      TODAY’S DATE___________________

 

Name_______________________________SS No._________________

Address_____________________________________________________

City_______________________  State_________   Zip_______________

Phone Number______________________  Cell Phone _______________

Age_____   Date of Birth_______________Gender:   Male____  Female____

Marital Status:   Married ___   Single ___  Widowed ___  Divorced ___  

                           Legally Separated ___ 

High School graduate?   Yes ___      No ___         GED?    Yes ___    No ___      

Highest grade completed ____     College:  1yr.     2 yrs.    3 yrs.   4 yrs.

 

Physical condition:    Excellent ___   Good ___   Fair ___   Poor ___ 

 

Are you under a physician’s  care for any of the following conditions?:

 ___ Arthritis                            ___ Hard of Hearing               ___ Back Pain

 ___ High Blood Pressure        ___  Fatigue                            ___ Diabetes

 ___ Heart Problems                ___   Low Blood Pressure

Other________________________________

Are you on medication for any of these conditions?     Yes ___    No ___

Physician’s name_______________________________________

Phone number___________________________________

 

Please provide 2 emergency contacts:

Name__________________________ Relationship____________

Address_________________________ Phone_______________

Name___________________________ Relationship___________

Address________________________  Phone_______________

 

TOTAL NUMBER OF PERSONS LIVING IN THE HOUSEHOLD_____

PLEASE LIST MONTHLY INCOME FOR ALL PERSONS IN THE HOUSEHOLD:

Social  Security                                                    $_____________

Supplemental Security Income                            $_____________

Annuity income                                                    $_____________

Pension income                                                   $_____________

Rental income received                                       $_____________

Income from stocks/bonds                                  $_____________

Wages or Salary                                                 $_____________

Other                                                                  $_____________

TOTAL MONTHLY INCOME                             $____________

 

 MEDICAL EXPENSES NOT COVERED BY INSURANCE $ ________

 

WORK EXPERIENCE   (List most recent first)

 

Occupation: _____________ Job Duties ______________________________

 

Occupation: _____________ Job Duties ______________________________

 

Why would you like to become a Foster Grandparent volunteer

_____________________________________________________________________

 

Have you had any experience mentoring or tutoring children?    Yes ___   No ___   

 

List memberships in any clubs or organizations:

__________________________________________________________________

List your hobbies and or special skills/talents:

__________________________________________________________________

When are you available to volunteer?       Mornings ____         Afternoons ____

What type of transportation will you use?    Car ___    Bus ___    Paratransit ___

Do you have auto insurance and a valid driver’s license?  Yes ___  No ___

Name of Insurance Company ________________________________________

Driver’s License Number ______________   State _________

Have you ever been convicted of a crime or felony?    Yes ___    No ___

All applicants being considered for the Foster Grandparent Program are subject to a State Criminal Background check and a Federal Background check.  Selection into the program is contingent upon a review of the applicant’s State and Federal background checks and the results of both background checks.  As the applicant, you have the right to challenge the factual accuracy of the results before any action is taken.  Any information obtained as a result of the background checks will remain confidential and will not be shared with any other sources.

By signing below, you authorize the Foster Grandparent Program to conduct a State Criminal Background check and a Federal Background check.

___________________________                       ______________

Signature                                                              Date

 

Please list three (3) character references NOT related to you:

                  Name                    Address                City                       Phone

1.____________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

 

I certify this information is correct to the best of my knowledge.

 

Applicant signature_________________________________      Date___________

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