Jane Beach, Activities Director Wayne County Nursing Home 1529 Nye Road Lyons, NY 14489 Phone: (315) 946-5673 ext. 4685 Fax: (315) 946-5671 E-mail: Jbeach@co.wayne.ny.us

Volunteer Application

Volunteer's Name: Date:

Address: City: State: Zip:

Home Phone: Work Phone: Cell Phone: Date Of Birth: 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 January February March April May June July August September October November December

E-Mail Address Emergency Contact: Phone:

Do You Work? Yes No If Yes, Where:

What Are Your Interests And/Or Hobbies?

Do You Have Transportation? Yes No Have You Ever Done Volunteer Work Before? Yes No

If Yes, Where Did You Volunteer?

What Type Of Volunteer Work Would You Be Interested In Doing? (Please Check All That Are Of Interest To You) Telephone Work Library Cart Clerical Work Read To Residents Companion Play Board Games Transportation Crafts Help With Special Parties/Holidays Letter Writing Vocal Talent Friendly Visits Help With Decorating Pet Visits Take Residents For Walks/Rides Resident Outings Provide Instrumental Talent What Type

Would You Be Available: WeeklyMonthlyOther

What Days Are You Available? MonTuesWedThursFriSatSun What Hours?

Why Do You Wish To Volunteer Here At The Wayne County Nursing Home?

Any Noted Health Problems?