Smile On Seniors.jpg
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  
  Card #  
  Exp. Date   
  CVV Security Code   What's This?