Senior Health Insurance Benefits Assistance Program SHIBA Volunteer Application

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Senior Health Insurance Benefits Assistance Program

Department

SHIBA Volunteer Application

Fill out this form and click the submit button or download a pdf version and submit it to SHIBA, 250 Church St. SE, Ste. 200, Salem, Oregon 97301-3921.

This application will be e-mailed to a SHIBA staff member who will review the application and contact you within two weeks. Thank you for your interest in becoming a SHIBA volunteer.

Contact information:
Date:
Full name:
County:
Mailing address:
City, State, Zip Code:
Your e-mail address:
Your phone:


Employment history:
Employer:
Dates:	From: to
Job title:
Type of business:
Supervisor:
Job duties:


Employer:
Dates:	From: to
Job title:
Type of business:
Supervisor:
Job duties:


Other employment:


Volunteer work history:
Organization:
Dates:	From: to
Job title:
Type of organization:
Supervisor:
Job duties:


Organization:
Dates:	From: to
Job title:
Type of organization:
Supervisor:
Job duties:


Other volunteer and community activities:
Special skills, interests, and hobbies:


Name	Relationship	Day-time phone	Evening phone
1.
2.
3.

Volunteer commitments (Please read carefully):

Will you be able to spend approximately three days within the next few months attending the SHIBA training course?
Yes No

Will you be able to attend bi-monthly meetings and trainings?
Yes No

Do you have reliable transportation to visit homebound clients?
Yes No

Are you willing to complete a record of assistance form for each client?
Yes No

How did you learn about the SHIBA program?

Why are you interested in joining the program?

Please describe any experience that you feel will help you as a SHIBA volunteer:

Call us if you have questions: (800) 722-4134.

Page updated: September 22, 2008

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