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C.I.E.D.C.
FOSTER GRANDPARENT PROGRAM
1800
Fifth Street
Lincoln,
Illinois 62656
VOLUNTEER
APPLICATION
NAME________________________________________ SEX____ SS
#___________________
ADDRESS_____________________________________
TOWN_________________________
PHONE_________________ AGE_____ BIRTHDATE_________________________________
PLACE
OF BIRTH_____________________ MARITAL
STATUS: M___ S___ D___ W___
HIGHEST
GRADE COMPLETED IN SCHOOL__________
MAJOR
PREVIOUS OCCUPATION_________________________________________
PREVIOUS
WORK WITH CHILDREN______________________________________________
COMMUNITY
ACTIVITIES______________________________________________________
HOW
DID YOU LEARN ABOUT THE PROGRAM____________________________________
MEANS
OF TRANSPORTATION: YOUR CAR____/
SR. TRANSPORTATION____
PHYSICAL
CONDITION: EX____ G____ F____
P____
PLEASE EXPLAIN:_______________
_____________________________________________________________________________
PHYSICIAN:
NAME________________________________
PHONE_____________________
ADDRESS_________________________________________________________
LIST
TWO CHARACTER REFERENCES WHO ARE NOT RELATIVES:
NAME________________________________ NAME__________________________________
ADDRESS_____________________________
ADDRESS_______________________________
TOWN________________________________ TOWN_________________________________
PHONE_______________________________
PHONE_________________________________
HOW
MANY PEOPLE LIVE IN YOUR HONE INCLUDING YOURSELF_________________
LIST
YOUR ENTIRE HOUSEHOLD INCOME BELOW:
SOCIAL
SECURITY $__________
SSI $__________
PENSION $__________
SPOUSE'S
S. S. $__________
PENSION $ __________
WAGES $___________
INTEREST
$__________
STOCKS $___________
BONDS $___________
OTHER
$__________
TOTAL
MONTHLY $__________
$___________
$___________
THE INFORMATION THAT I HAVE GIVEN IS TRUE AND
ACCURATE TO THE BEST OF MY KNOWLEDGE.
APPLICANT'S
SIGNATURE_______________________________
DATE______________
The
Foster Grandparent Program of Logan, Mason, Menard, Piatt, Macon,
DeWitt,‑ Fulton, Sangamon, and McLean Counties is a National
Senior Service Corporation Program sponsored by central Illinois
Economic Development Corporation.
**
ALL INFORMATION WILL BE KEPT CONFIDENTIAL
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