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ABOUT
–
OUR LEADERSHIP
OUR STORY
JOIN OUR TEAM
E-NEWSLETTER
–
PHOTO GALLERY
ANNUAL REPORT
LOCATIONS
CONTACT US
PROGRAMS
–
REFER A CLIENT
DIABETES SERVICES
DIABETES DAYTON
CANCER SERVICES
HOME DELIVERED MEALS
SENIOR FARMERS MARKET
WELLNESS SERVICES
–
CARRIE’S CAFE & SENIOR DINING CENTERS
HELP-AT-HOME
PERSONAL EMPOWERMENT SERVICES
HIV/AIDS NUTRITIONAL SUPPORT
SENIOR PET CARE
VISITING NURSES
SUPPORT
–
DONATE
PLANNED GIVING
LEGACY ENDOWMENT CAMPAIGN
ENDOWMENT RESOURCE DIRECTORY
LIFECARE ALLIANCE STORE
–
SHOPPING REWARDS
Cancer Thrift Shops
SOCIAL ENTERPRISE
VOLUNTEER
VOLUNTEER APPLICATION
Blog
Referrals
Volunteer
Give Now
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Help At Home Volunteer Form – Title 3B
Your First Name
(Required)
Your Last Name
(Required)
Client First Name
(Required)
Client Last Name
(Required)
Client Address
(Required)
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date of Service
(Required)
MM slash DD slash YYYY
Mileage
(Required)
Time Start
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Time End
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Total Hours Serviced
Tasks Completed :
Grocery Shopping/Click List Pick Up
Laundry
Vacuuming
Dusting
Pet Care (walking, tending to litter box, brushing etc.)
Trash Removal
Other (please elaborate in comment section below)
Client Signature
(Required)
Clients , please enter your name here
Volunteer Signature
(Required)
Volunteers, please enter your name here
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