Volunteer Guardian Application (Page 2 of 7) in pdf

Volunteer Guardian Application Page 2

4..

Do you have medical issues (including physical, mental health or substance abuse) that may impact your ability to

serve as a volunteer guardian of another person?

Yes

Do you have access to reliable transportation? (2 visits per month to your person are a requirement of the program)

Yes

If no, please explain:

6. Have you ever been charged with, or convicted of a crime? This may not exclude you as a candidate, but you should

be willing to discuss the circumstances at the appointment hearing: A fingerprint report is required by the court at the

time of filing: We can talk to you about this at your interview.

Yes

Expunged

If yes, please list charge(s):

Date of Arrest / Disposition:

7. List current community activities and memberships, if any.

8. Is there a group, or specific gender that you are particularly interested in working with? Check all that apply.

We use this to match you with someone you would enjoy helping.

Male

People with MR/DD

Female

People with mental illness

No Gender Preference

People with illnesses related to aging

Is distance a factor for you ?

People with other mentally disabling illness

If yes, List Geographical area of preference/Area of Town:

(i.e. stroke, traumatic brain injury)

People who cannot communicate (i.e. it is not important to

I would be comfortable helping any of the above

me that the person I help can acknowledge my efforts)

Page 2 of 7

Volunteer Guardian Application Page 2