Name(required) Date of Birth(required) Address(required) Phone(required) Email Education: (highest level achieved)(required) Highschool Junior College College Post Graduate/Degree(s) Languages spoken other than English: (Indicate level of competency - excellent / good / fair / poor speak / read / write) Are you currently employed? If so, what do you do and what is your work schedule? If retired or in school, please indicate your schedule too.(required) Why are you interested in becoming a HICAP Volunteer Counselor?(required) Do you have any health, legal, or insurance background? (This is not a requirement.) If so, please describe.(required) What experiences have you had in doing volunteer work?(required) Are there any other experiences you’ve had that would aid you in being a HICAP Counselor? Do you have any hobbies / special skills / interests? How did you hear about the HICAP volunteer program?(required) Please provide (or bring with you to the interview) two references we can check with: HICAP is looking for volunteers who will actively participate in the program for a year or longer. Please read the following statements carefully. You acknowledge your willingness to participate in the program and adhere to its procedures. I have read the HICAP Volunteer Counselor job description, am aware of the duties and responsibilities, and am willing to undertake them. (required) Yes No I am willing to work as a HICAP Volunteer Counselor for a minimum of one year at an average of ten hours per month.(required) Yes No I am willing and able to attend the bi-monthly volunteer training sessions.(required) Yes No I have a valid California drivers’ license and adequate personal automobile insurance. (The State Department of Aging requires this for those who will be driving their private vehicle to and from HICAP sites during normal business hours.)(required) Yes No Return to the Volunteer Page.