WSU Ride-Along March 13-14, 2024

This form is to be completed only by Wayne State University students 18 and older currently enrolled at least half-time in a degree seeking program.

Name of Academic Program:

First Name

Last Name

Street Address

Apt #

City

State

Michigan

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District Of Columbia

Florida

Georgia

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

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Zip

Enter Email Address

Confirm Email Address

Phone Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Check volunteer opportunities of interest to you:

Home-Delivered Meals Driver

Serving Meals at Site

Packaging Meals

Registration Desk

Liquid Nutrition Program

Other

Can you commit to a specific length of service?

Yes

No

Days and hours available:

Please select one of the following time commitments. Time commitments are generally available between 8am-2pm Monday through Thursday

2-hour commitment: Assisting with packaging of home-delivered meals, serving congregate meals and/or assisting with site prep and clean up

3-hour commitment: Delivering meals to home-delivered meal clients. (This commitment requires a valid driver's license, auto insurance, and vehicle)

4-hour commitment: Assisting with packaging of home-delivered meals, and delivering meals to home-delivered meal clients (This commitment requires a valid driver's license, auto insurance, and vehicle)

Do you have a valid drivers license?

Yes

No

Do you have current vehicle insurance as required by Michigan law?

Yes

No

Have you ever been convicted of a criminal violation (misdemeanor or felony) of the law other than minor traffic violations?

Yes

No

If "Yes" please explain (Type "N/A" if not applicable):

Are you volunteering to satisfy court ordered community service?

Yes

No

I understand that the Wayne County Department of Senior Services, as a condition of volunteering is required to run a complete check of any possible criminal record(s) that I might have. I understand that any information found regarding convictions or felony charges might result in my being refused a volunteer opportunity with the County of Wayne.

I authorize Wayne County to perform necessary background check to volunteer.

I do not authorize Wayne County to perform necessary background check to volunteer.

Date of Birth:

Gender:

Race:

I attest the information provided.

I agree.

I do not agree.

Electronic Signature:

Date:

Wayne County Service Assistant

Senior Services

Senior Services

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