Application for Smile on seniors Volunteer Name: Number: Email: Address: Volunteer Options (check one): I am able to visit 1 visit per week 2 visits per month for special events. In your free time what do you like to do? Check all that apply: Playing ball Playing piano Reading Taking walks Board games Card games Craft projects Other When SOS has an event, would you like to participate? YesNo In what way? Check all that apply: Making calls Setting up Shopping Planning At the event only Other If you were a senior being visited, what are a few things that would interest you? What day of the week and time work best for your visit? I affirm that no moneys or gifts shall be accepted by me from any senior at any time and I will do all within my power to uphold the mission and integrity of the Smile On Seniors™ program. Optional Donation Form: I will send a check to: Donation Amount: Chabad of Oxnard Last name 3810 Channel Islands Blvd First name Suites J-K Address Oxnard, CA 93035 City/State/Zip Phone Email CC Type Master Card Visa Amex Select Card # Exp. Date 01 02 03 04 05 06 07 08 09 10 11 12 Select 2014 Select 2015 2016 2017 2018 2019 2020 CVV Security Code What's This? This page uses 128 bit SSL encryption to keep your data secure.