Volunteer Application

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Full Name *
Street Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone Number *
Email Address *

During which hours are you available for volunteer assignments? Check all that apply. *
Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMSunday PMAny day, any time
Tell us in which areas you are willing to serve. Please check all that apply. *
Frederick CountyAnne Arundel CountyMidshore (Talbot/Caroline) CountiesWashington CountyMontgomery County

Do you currently use the following?
CaneWalkerRollatorWheelchairScooter
Can you get in/out of a house by yourself? *
YesNo
Can you get in/out of a car by yourself? *
YesNo
Are you able to cook? *
IndependentlyNeeds Assistance
Are you able to do housework? *
IndependentlyNeeds assistance
Are you able to drive or use public transportation? *
IndependentlyNeeds assistance
Are you able to manage your finances? *
IndependentlyNeeds assistance
Are you able to manage medications? *
IndependentlyNeeds assistance
Are you able to do shopping/errands? *
IndependentlyNeeds assistance
Are you able to use your phone to lookup numbers? *
IndependentlyNeeds assistance

Do you have:
CancerCholesterolChronic PainCOPDDiabetesHeart ConditionHypertensionMental Health ConditionRenal disease with or without dialysisOther
Are you visually impaired? *
NoSome vision lossBlind
Eye disease/condition
Are you hearing imparied? *
NoneSlight impairmentExtensive impairmentWear hearing aidsNeed hearing aids
Primary Care Physician name *
PCP phone number *
Medical Insurance *
Secondary Medical Insurance
Hospital of choice *
Self-reported physical health *
ExcellentGoodFairPoor
Are you: *
Alert and orientatedConfused/forgetfulSignificant memory loss
How often do you feel lonely? *
Hardly or neverSome of the timeOften
How often do you get out of the house? *
Appointments only1-3x a week4-6x a weekEvery day
How often do you speak with friends and family? *
Not at all1-3x a week4-6x a weekEvery day

Do you have an advanced directive? *
YesNo
Would you like more information about advanced directives?
YesNo
Do you have an emergency response system? *
YesNo
Would you like more information about emergency response systems?
YesNo
Do you have a working smoke detector? *
YesNo
Would you like more information about obtaining a working smoke detector?
YesNo
Are you receiving services from:
Meals on WheelsSNAP
Are you receiving home healthcare? *
YesNo
If you are receiving home healthcare, select the service(s) you receive:
NursePTOther
Do you need any services? *
YesNo
Needed service(s):
Do you smoke? *
YesNo
Are you bilingual? *
YesNo
Which language(s) do you speak?

Name *
Relationship *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Home/Cell Phone *
Other Phone

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. *

What do we need to know about you in order to make a safe and effective match. (Ex. I am very social, I don’t mind multiple trips, I use a cane, I’m allergic to cats….etc) *

Reference #1 Street Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Reference #1 Phone Number *
Reference #2 Street Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Reference #2 Phone Number *
Membership Agreement Upload Download the Membership Agreement form at the top of this page. Fill it out, sign, scan or take a photo of it and upload it here. If you don’t have scanner capabilities, you can fill out a hard copy at orientation.

We are committed to ensuring that no person is excluded from participation in or denied benefits of the transits services we offer.