Adopt-a-Senior Volunteer Application

2. Adopt-a-Senior Volunteer Application

   
   

   The City of Richmond's Adopt-a-Senior Program connects community volunteers to seniors in Richmond and North Richmond who need help with basic maintenance services in their front yard, back yard, and/or sidewalk. Services may include: cleaning up debris and litter; removing weeds and tall grass; trimming and pruning plants; painting; and more. The Adopt-a-Senior Program does not provide any home repairs or other services that take place inside of the home.

   
   

   The Adopt-a-Seniors Program provides garbage bags and gloves upon request. Volunteers are to use their own tools to provide services. Volunteers who live in Richmond or North Richmond may also sign up for the Richmond Tool Library to borrow tools for free.

   Please note, ALL VOLUNTEERS must complete additional processing steps that include:

   • A new tuberculosis (TB) test or TB test results from within the past 2 years. New TB tests are provided at no cost to the volunteer at Concentra Medical Center in Richmond. Staff will provide further instructions and a pre-authorized form to volunteer applicants.
   • A Live Scan fingerprinting appointment at Richmond Police Department, provided at no cost to the volunteer. Staff will provide further instructions and a pre-authorized form to volunteer applicants.
4. Personal Information
6. First Name*
7. Last Name*
8. Date of Birth*
   Date of Birth
10. Gender*
    -- Select One --MaleFemalePrefer not to say
11. Address*
13. City*
14. State*
15. Zip Code*
17. Email Address*
18. Preferred Phone Number*
20. Volunteer Information
22. Volunteer Commitment*

    1. Long Term (>6 months)
    2. Short Term (<6 months)
    3. One Time
23. Volunteer Availability (check all that apply)*

    1. Morning
    2. Afternoon
    3. Evenings

    1. Weekends
    2. Weekdays
24. Volunteer Frequency*
    -- Select One --One time onlyOnce every 2 weeksOnce a monthOnce every 2 monthsNo preference
26. How would you like to be matched with a senior?*

    1. A senior who lives in my neighborhood
    2. No preference (any senior)
27. Do you have professional training in any of the following fields? (Check all that apply)*

    1. Landscaping
    2. Gardening

    1. Painting
    2. None of the above
29. Please describe your professional training.
31. Describe your most recent volunteer experience.*
33. Why are you interested in volunteering with Richmond? *
35. Languages
37. Fluent Languages (check all that apply)*

    1. English
    2. Spanish
    3. Other
38. Other Fluent Languages
40. Emergency Contact
42. First Name*
43. Last Name*
44. Relationship: *
45. Phone: *
47. References
49. First Name*
50. Last Name*
51. Phone Number*
52. E-mail*
54. First Name*
55. Last Name*
56. Phone Number*
57. E-mail*
59. First Name*
60. Last Name*
61. Phone Number*
62. E-mail*
64. Volunteer Service Agreement
    Please carefully read the following statements.
    
    I agree to volunteer my services to the CITY OF RICHMOND, California ("City") Adopt-a-Senior Program ("Program").
    
    If volunteer is under 18 years of age, a parent’s/guardian’s name and phone number are required.
    
    I acknowledge that there is no salary or other compensation of any kind to be provided by the City for my services as a volunteer.
    
    I understand and agree that under no circumstances shall I enter my adopted senior's residence.
    
    I agree to bring my own tools to complete services for my adopted senior. I understand that I may ask my adopted senior for use of their personal tools, and I agree that the City and/or my adopted senior will not be responsible for any injury that I may sustain while using the personal tools.
    
    I agree to complete a metrics form for each time I provide services, and I further agree to submit the form to the City within two (2) weeks after the day the service was completed.
    
    I understand that the Program is under no obligation to accept all interested volunteers.
    
    I understand that all volunteers must be fingerprinted and undergo a state and federal background check as well as a tuberculosis test.
    
    I understand that the City of Richmond may photograph or videotape the events or activity in which I am (or my child is) participating. I give my permission for the City to use photographs or videotape of me (or my child) for the purpose of promoting the City of Richmond and its services/programs. I give my permission with the following understanding: No compensation of any kind will be paid to me (or my child) at this time or in the future for the use of my (or my child's) likeness.
    
    I hereby release the City of Richmond, its officers, agents and employees from any and all liability, claims, cause of action, or actions, arising out of or occasioned by bodily injuries or property damages sustained by me as a result of my volunteer services to the City.
    
    I understand that during the course and scope of my volunteer services to the City, I will be covered under the City's Worker's Compensation self-insurance. I also understand and agree that my sole remedy for any injury that I may sustain during the course and scope of my volunteer services to the City, which is covered by Worker's Compensation, shall be through the City's Worker's Compensation self-insurance coverage. I waive any other right or remedy that I may have available to me for the injuries described above.
    
    I also acknowledge and agree that my services may be terminated for any reason, or for no reason, and at any time by the City without notice or hearing.
    
    I, the undersigned, certify that the information stated on this application is true, complete and correct to the best of my knowledge and belief and is made in good faith. Any false statements made by me may be used as a basis of rejection for this application.
    
    I further state that I have carefully read the foregoing release and agreement and know the contents thereof, and agree of my own free accord.
66. Please enter your full name below to indicate your agreement to the terms and conditions.
    FAILURE TO ENTER YOUR FULL NAME IN THIS APPLICATION MAY RESULT IN A DELAY IN PROCESSING.*
68. If you are under the age of 18, please include your parent or guardian's first and last name. Please type 'N/A' if you are over the age of 18.*
69. If you are under the age of 18, please include your parent or guardian's phone number to confirm permission has been granted. Please type 'N/A' if you are over the age of 18.*
71. Demographic Information (Optional)
73. 
    What is your age group?
    -- Select One --Under 12 years old12 - 17 years old18 - 24 years old25 - 39 years old40 - 59 years oldAbove 60
74. What is the highest level of education that you have completed?
    -- Select One --Less Than High SchoolSome High SchoolHigh School or EquivalentSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeProfessional DegreeDoctorate Degree
75. What best describes your current employment status?
    -- Select One --Full time employmentPart time employmentUnemployed / Looking for workUnemployed / Not looking for workStudentRetiredOther
77. How did you find out about us? *

    1. City of Richmond Webpage
    2. A Friend
    3. Flyer

    1. Facebook
    2. Twitter
    3. Other
78. Would you like to sign up to receive e-newsletters from us?*

    1. Yes
    2. No
80. If you checked other, please specify.
Leave This Blank:


81. Submit Submit and Print

* indicates a required field