Please take a few minutes to fill out and submit this application. We will contact you soon after receiving your information. Note: Please do not use any parentheses, brackets, or other special characters when filling out this application.

Name:

Date of birth (mm/dd/yyyy):    /    / 

Street address #1:

Street address #2:

City: State: Zip:

Home phone: Work phone:

E-mail:

Permanent address (if different from above):

Workplace:

Job Title:

Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone:

How would you like MATCH-UP to contact you?

home phone
work phone
letter
e-mail

How did you hear about MATCH-UP?

MATCH-UP has a variety of volunteer opportunities. Please check all that interest you.

Friendly Visitor
May include letter-writing, reading to the visually impaired, helping with bill paying, light errands, escorting on occasional shopping trips, providing telephone reassurance.

Medical Escort with car without car
Involves taking a frail or disabled person to a medical appointment, providing emotional and/or physical support, and helping him or her navigate through medical buildings and hospitals.

One-time Assistance
May involve taking an elder to visit a loved one in a nursing home, taking an elder to a special event or non-medical appointment, packing or unpacking boxes, etc.

Office Volunteer
Administrative, receptionist, and program assistance at the MATCH-UP office.

PetPals
Visit with your dog at nursing care facilities and rest homes. (If you are interested in the PetPals program, please complete the PetPals application as well.)

Strong for Life
An at-home exercise program for seniors. May include stretching, strengthening, flexibility and balance. The Walking Buddies specialty program concentrates on the importance of walking by enabling seniors to take walks comfortably and safely with a volunteer.

If you are interested in being matched as a Friendly Visitor, please answer the following questions.

Which neighborhoods are most convenient for you to visit? Check all that apply.

Any
Allston/Brighton
Back Bay
Beacon Hill
Brookline
Charlestown
Chinatown
Dorchester
East Boston
Fenway
Hyde Park
Jamaica Plain
Mattapan
Roxbury
Roslindale
South Boston
South End
West Roxbury

Please check the following boxes if you wish to indicate "yes."

Will you travel to visits by car? Will you rely on public transportation?

Would you consider being matched with a person who is blind?

Would you consider being matched with a disabled person?

Would you consider visiting someone in a nursing home?

Are you interested in being matched with a person whose ethnicity is different from your own?

Do you prefer visiting a man? a woman? no preference

Would you be willing to visit someone with a dog, cat, or other pet? If no, please list unacceptable pets:

Do you have any allergies or conditions that would limit your ability to volunteer in someone's home?
If yes, please describe:

Previous volunteer experience (not required)

Organization #1

Dates

Contact person

Organization #2

Dates

Contact person

References (other than family)

Reference #1

Relationship

Daytime phone

Reference #2

Relationship

Daytime phone

MATCH-UP takes great care in making matches that are gratifying for both the volunteer and the elderly recipient. To help us match you with a compatible senior, please tell us about yourself.

What are your interests and hobbies? (favorite music, books, TV shows, sports, movies, food, leisure activities, etc.)


What languages do you speak?

What else would you like us to know about your personality and background?


Why do you want to work with the elderly?

Because MATCH-UP and our supporters embrace diversity, we are frequently asked to describe the make-up of our volunteer community. For this reason, we ask volunteers to tell us how they identify themselves. This information is used for statistical purposes only and is not required.

Religious affiliation:

Congregation (if any):

Place of birth:

Race (check all that apply): White Black or African American Asian Other

Ethnicity and/or Nationality: