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People Helping People Client Application |
Volunteer Center of San Gabriel ValleyPeople Helping People Senior Application 2500 E. Foothill Blvd., Ste. 101 Pasadena, CA 91107 (626) 792-6118 Fax (626) 792-8567 Date ___________________ Last Name: ___________________ First Name: _____________________ Address: _____________________________________ City: ___________________ Zip Code: ________________ Home No.: Cell No.: _______________________________ E-Mail: ____________________________ Date of Birth: ________________________ How many people live in the household: _________________
Emergency Contact: __________________________ Phone: _______________________
Assistance Requested_
___________ Yard Work __________ Friendly Visitation
________ House Work
Specific Materials Needed ____________________________________________________ _______________________________________________________________________
Desired frequency of visits by volunteer
Day of the week available:
Monday ________ Thursday _________ ________ 1 day a month
Tuesday ________ Friday ___________ _________2 days a month
Wednesday _______ Saturday__________ _________3-4 days a month
Health conditions that should be noted: ________________________________________________________________________
Notes: ___________________________________________________________________
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