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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HUMAN SERVICES Application for Foster Grandparent Program Instructions 1. You must be 60 years of age or over to apply. 2. Please fill all spaces that apply to your situation. If you need assistance please feel free to ask the person who furnished the application. 3. Print or type the information if possible. 4. Please list any volunteer experiences in section for employment. 5. Applicants will be interviewed by the Director of Foster Grandparent Program. FGP VOLUNTEER APPLICATION (St. Thomas, USVI) _________________________________ (Name Typed or Printed) _________________________________ (Signature) _______________ (Date) Address: __________________________________________________________________ (Street, City or Town, Zip Code) _______________ __________________ ____________ ___________ Telephone No. Social Security No. Medicare No. Medicare No. _____ __________ _______________ Age Birth Date Birth Place Married__Single__Widowed __ Years of School Completed_____ Previous Occupation___________________________ Physical Condition: Excellent____ Good____ Poor____ Please Explain: ________________________________________________________________ Name, address, and phone number Of contact in Emergency ________________________________________________________ Name address, and phone Number of Physician: ___________________________________________________________ No. of Persons Living in your home: _____ Income Sources & Amounts Name(s) of Legal Dependents: __________ Social Security $____________ _____________________________________ SSI $____________ _____________________________________ Amunity Income $____________ Your Estimated Net Income for the Next Pension Income $____________ 12 Months $__________________ Net Rest Income $____________ Total Income for Your Entire Interest Income $____________ Household: Income from Stocks & Bonds $____________ Current_____________ Public Assistance $____________ Next 12 Months____________ Other $____________ Total $____________ Tell why you wish to be a Foster Grandparent: _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ What kind of transportation do you plan to use? ____________________________________ ______________________________________________________________________________ Membership in Senior Clubs or Organizations: _____________________________________ ______________________________________________________________________________ Hobbies and Special Skills: ______________________________________________________ Language(s) spoken: ____________________________________________________________ Willing to Serve: Mornings______________ Afternoons__________________ Two Character References (Not Relatives): Name: __________________________ Phone # _________________ Address: ___________________________________________ ___________________________________________________ Name: ___________________________ Phone #__________________ Address: ____________________________________________ ____________________________________________________ VOLUNTEER ENROLLMENT RECORD AND INSURANCE FORM Miss. Mrs. Name Mr. ______________________________________________________________ (Last) (First) Address__________________________________________________________________ State______________________ Zip Code____________________ Phone# ________________ Birth Place__________________________ Language Spoken_______________________ Public School________________________ High School _________________________ College________________________________________________________________________ Single_______ Married___________ Widowed_____________ Emergency Contact Name_____________________ Phone_________________ Address_____________________ City____________________ State_____ Station_______________________ Assignment______________________________ BENEFICIARY (S) FOR ACCIDENT INSURANCE Name_____________________________ Relationship_____________________ Address________________________________ City______________________ State_______ Name______________________________ Relationship_____________________ Address________________________________ City_______________________ State_______ __________________________ _______________________ Signature Date