Welcome to the DOI


Volunteer Application


* Required Field
Personal Information
 
Last Name*:     First Name*:     Middle Name:  
Street Address*:  
City*:   ST*:   ZIP*:
Mailing Address:  
City:   ST:   ZIP:
Home Phone*:   Cell*:   Work*:
Email:   Date of Birth:  


Employment
 
Employer (Current or Former, "none" if retired):
Supervisor Name: Phone:
Position:


Education
 
High School   Current Student
College   If yes, would your volunteer work be related to a school project or requirement?
Graduate School   If so, describe:


Availability
 
How many hours are you available for volunteer assignments*?
Hours per Week:   Hours per Month:  
Check the days and times you are available for volunteer assignments*.
MondayTuesdayWednesdayThursdayFriday
Mornings
Afternoons


Interests
 
Tell us in which areas you are interested in volunteering*.
Data entry Special events Counseling on medicare
Help with billing issues Public speaking Outreach
Fraud Other:
Are you applying to be a SHIBA, or a SMP volunteer*?    
Name of the SHIBA/SMP Coordinator who recruited you: