Date: Month Day 20

Name of agency/station:

Address:

Volunteer coordinator/contact:

Number of volunteers requested:

Volunteer job title(s):

Responsibilities/duties:

Requirements:

Will training be provided for the volunteer(s)? If so, please describe:

When will volunteer(s) be needed; i.e., morning, afternoon, evening?

Are new volunteers accepted only at specific times of the year?

Is supervision provided?

Name of supervisor:

What benefits will this placement have for the volunteer; i.e., companionship, training, conferences, workshops, etc.?

Are volunteers reimbursed for expenses?   Mileage Bus Parking Meals
Other

Are volunteers covered by accident insurance?

Does Seniors Helping Others have permission to advertise this request in the media?