Contact Us

ElderNet provides a safety net for older and disabled adults to help them remain in their homes with dignity and strengthens food and financial security for all community members in need of support.

Name

Date of Application

Date of Birth

Address

City

State

Zip

Email

Home Phone

Cell Phone

Which do you prefer to be contacted on?

Email

Home Phone

Cell Phone

How long have you lived in Pennsylvania?

No, I have not lived in Pennsylvania for 2 years

Yes, I have lived in Pennsylvania for longer than 2 years

How did you hear about ElderNet?

Race (For Reporting Purposes Only)?

American Indian/Alaskan Native

Asian

Black/African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Are there any skills or talents that you would like to offer?

Do you speak any other languages?

What company do you work for and what is your occupation?

Do you belong to any organizations?

Do you volunteer with any other organizations?

How would you like to help?

Other Information Needed:

As part of ElderNet’s application process, we will need a few more pieces of information from you:

A copy of your driver’s license or other government-issued ID. This will be used to complete a
background check for all volunteers.
Have you used any other first or last names? This will help complete the background check.
A copy of your car insurance card. For volunteers who will be escorting participants only. We
will also need updated insurance information when your policy is renewed or changed.
Three references.

Reference 1

Name

Phone Number

Email

How Long Have You Known Them?

Add Reference Remove Reference

Reference 2

Name

Phone Number

Email

How Long Have You Known Them?

Add Reference Remove Reference

Reference 3

Name

Phone Number

Email

How Long Have You Known Them?

Add Reference Remove Reference

Volunteer Application

How would you like to help?

Other Information Needed:

Reference 1

Reference 2

Reference 3

Get In Touch