TAP Program Volunteer Registration Form

TAP Program Member Enrollment Form

Date: ______General Information

Address (Number & Street):

City: State: Zip code:

Home Phone: Cell Phone:

Date of Birth: Gender: __ Male __ Female

Race / Ethnicity (please check all that apply):

__African American __Caucasian __American Indian /Alaskan Native __Asian __Arab American __Native Hawaiian/Pacific Islander

__Hispanic/Latino __Other

Sources of Income (please check all that apply):

__Medicaid __Medicare __Social Security Disability (SSD)

__Social Security (SS) __Veterans Benefits __Supplemental Security Income (SSI)

Income Range (information used for funding reporting purposes only, does not determine eligibility):

__ Below $9,999 __$10,000 - $19,999 __$20-000 - $29,999

__$30,000 - $39,999 __$40,000 - $49,999 __$50,000 - up

Do you live alone? __Yes __No

Personal Information (the following information is used to match interests of volunteers and members)

Foreign Language Skills:

Level of Fluency: __Fluent __Able to Read __Some Training

Marital Status: Religion:

Hobbies and Interests: ______

Primary Physician Contact Information

Name: Office Phone: ______

Please list any health issues of which the TAP office or the TAP Volunteer should be aware:

______

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Emergency Contact Information

Name: Relationship:

Address (no., street, city, state, ZIP):

Day Phone: Evening Phone:

------

Name: Relationship:

Address (no., street, city, state, ZIP):

Day Phone: Evening Phone:

Program Information

When do you wish to receive calls?

Days: __Mon __Tues __Wed __Thurs __Fri __Sat __Sun

Times: __Morning __Afternoon __Evening

How many calls would you like to receive each week?___

I am interested in receiving: (select one or both) __socialization calls; __well-being check calls

Referral Information

Name: Relationship:

Organization: Phone:

TAP Site Information (to be completed by office staff)

TAP Site: Coordinator:

Call Schedule Volunteer’s Name Home Phone Other Phone Call Details (Day & Time)

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