Plateau Valley Faith in Action Volunteer Registration Form

Please print this page, complete the following information and mail to:
PV Community in Action, 58128 Hwy 330, Collbran, CO 81624
or fax to 970-487-0214

Title: First Name: Last Name:

Address:

City: State: Zip:

Home Phone: Work Phone: EMail:

Birthdate: Sex: M/F .

Church/Organization: Location:

Please check the times that you are available:

. Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning . . . . . . .

Afternoon . . . . . . .

Evening . . . . . . .

How many hours are you willing to volunteer? Per week: Per Month:

Do you have transportation to get to volunteer assignments? Yes No

If no, how will you get to volunteer assignments? .

Do you have any physical limitations? If so, please list: .

Please check or circle ways in which you are able and willing to help:

Visiting with a person Reading to a person Reassurance calls

Transportation (Local = PV) (Grand Junction = GJ)

to medical appointments
(PV) (GJ)

to social activities
(PV) (GJ)

to church
(PV) (GJ)

to other places
(PV) (GJ)

Shopping with a person Shopping for a person Writing Letters

Errands with a person Errands for a person Paperwork/Record keeping

Chores Rake Leaves Cut Grass

Shovel Snow Trim Shrubs Plant/upkeep flower garden

General minor repairs Light Housekeeping Laundry

Meal Preparation Respite Care .

Other (please list):

.

Community In Action
A Neighbor's Independence Depends on You

PV Community in Action Volunteer Registration

Community In Action A Neighbor's Independence Depends on You

PV Community in Action Volunteer Registration

Community In Action
A Neighbor's Independence Depends on You