LIFE AT HOLY BLOSSOM
Jewish Service Network Day Trip
Kids Mitzvah Club
survey
Bikur Cholim Volunteer Application
Date
*
Date
Name
*
First
Last
Age
*
Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
Gender
*
Male
Female
Home Phone
*
Work Phone
*
Cell
*
Email
*
I would like to offer fellow-congregants in need:
*
Home visit
Occasional transportation /to synagogue/medical appointments/for shopping
Hospital visit
Telephone contact
Nursing home visit
Occasional meals
Are you a driver with a car?
*
Yes
No
I prefer to visit people who are (check all that apply):
*
Children
Teens
Adults
Seniors
I prefer to help/visit during the
*
Day
Evening
Weekend
In order to make best use of your skills, please include any relevant experience:
*
Submit