SENIOR COMPANION PROGRAM (SCP)/FOSTER GRANDPARENT PROGRAM (FGP)

OF NORTHERN & CENTRAL ARIZONA

APPLICATION & ENROLLMENT FORM (Substitute W-9)

PO BOX 5063, FLAGSTAFF, AZ 86011-5063

PHONE: (928)523-3560; FAX: (928)523-9189; TOLL FREE; (866) 856-3017

Date of Application: ____________ Please circle the program for which you are applying:     SCP            FGP

Name: ___________________________________________Other Name
or Other Alias in_______________

Last
7 Years

Mailing Address: ___________________________________________________________________________

(City)                                                      (State)                    (Zip)

Telephone: __________________________________ Message
Number:
______________________________

Social Security or Tax Identification #:__________________
Gender:  ______ Date of Birth:
______________

Please circle whether you drive and can provide your own
transportation:           Yes                  No

Drivers License Number & Expiration Date:
______________________________________________________

Languages spoken
other than English: ________________________________________________________

Other experience
relating to SCP or FGP and why you would like to become an SCP/FGP volunteer:
__________________________________________________________________________________________

__________________________________________________________________________________________

Please circle your volunteer preference
time:         Morning          Afternoon       No
Preference

Number of people
living in your household including yourself: ____________________________________

MONTHLY
INCOME (confidential).
Include all sources and amounts for yourself & others living in your
household:

Social
Security              _________________                          SSI                                          _________________

Pension/Retirement                   _________________              Net
Rent (paid to you)              _________________

Saving
Account Interest            _________________              Stocks/Bonds                           _________________

Salary
or Wages                       _________________              Other                                       _________________

Total Monthly Income_________________

Total Monthly Income x 12 Months =_______________

Please list two character references that are NOT related to you.  We WILL
be contacting each reference listed:

Name                           Address                                   City/State                     Zip                   Phone
#

1.
____________________________________________________________________________________

2.

Emergency Contact
Name: ____________________________ Address:  _____________________________

City/State:
_____________________________________Zip:  ____________Phone No.:  _________________

Relationship to you:
_____________________________

Insurance
Beneficiary:

You MUST
name a beneficiary for OUR
insurance carrier in case of accidental death or dismemberment while
volunteering:

Name: _________________________________________Address:____________________________________

City/State:
_____________________________________Zip:  ____________Phone No.:  _________________

Addresses for past
seven years, other than current address:

Street Address                                                 City/State                     Zip
Code                      From    To

__________________________________________________________________________________________

__________________________________________________________________________________________

Employment History:

Company
Name & Address                             Job
Title                       Supervisor                    From    To

__________________________________________________________________________________________

__________________________________________________________________________________________

Have you ever been
convicted of anything other than minor traffic violations?    YES                 NO

If yes, please explain:
________________________________________________________________________

_________________________________________________________________________________________

I fully understand
that, if accepted into either the Senior Companion or Foster Grandparent
Program, I am a volunteer in the program and not an employee of Northern Arizona
University or the State of Arizona.  Also, as a volunteer, I realize that I
receive a tax-free stipend and not a taxable wage for my volunteer efforts.  If I drive, I certify that I am
covered and will maintain the Arizona
State minimum
automobile liability insurance.

I hereby certify that
under penalty of perjury that the answers given above is true and correct to
the best of my knowledge and belief and agree to have a background check
completed.

Applicant Certification, under
penalties of perjury, I certify that:

a.      The number shown on this form is my correct
taxpayer identification number (social security number).

b.       I am not subject to backup withholding.

c.       I am a person residing in the u.s.

Signature:

_____________________________________________________________

Date:

____________________________________________

I have viewed an official picture
Identification Card for the person listed on this application.

The Picture ID Card I viewed was a     ____Driver’s License               _____State
of AZ Picture ID

_____Passport ID        ____Other—please
identify:_________________________________________________

Volunteer Coordinator Signature:________________________________________Date:__________________

FOR OFFICE USE ONLY:               ENROLLMENT
DATE: ______________________

VOLUNTEER
STATION: ____________________

TRAINING
COMPLETED: ___________________

DIRECTOR SIGNATURE: ___________________

1          2          3          4          5

RELEASE AND AUTHORIZATION

In connection with this request, I
authorize all corporations, companies, former employers, credit agencies,
educational institutions, law enforcement agencies, city, state, county and
federal courts, military services and persons to release information they may
have about me to the person or company with which this form has been filed, or
their agent, Fidelifacts, 3030 N. Central Ave., Ste. 502, Phoenix, Arizona and
releases all parties involved from any liability and responsibility for doing
so.

I also authorize the procurement of
an investigative consumer report and understand that it may contain information
about my backgrounds, mode of living, character, and personal reputation.  This authorization, in original or copy
form, shall be valid for this and any future reports or updates that maybe
requested.  Further information may
be available upon written request within a reasonable period of time.

I authorize the National Personnel
Records Center,
St. Louis, Missouri or other custodian of my military
records to release to Fidelifacts/Phoenix information or photocopies of my
military records, or only the following information/records:
________________________________________________________________________

_________________________________________________________________________________________

Service #:  __________________________________
Branch of Service:
__________________

From:  _______________To:  __________________

______________________________________________________________________________

APPLICANT’S SIGNATURE                                                                                                DATE