Member Registration

Please complete one form per person.

Applicant Information

Last NameFirst NameMIStreetCityZipTelephoneCell PhoneEmailDate of Birth

Male

Female I prefer to be contacted by

Telephone

Cell phone

EmailEmployerEmployer PhoneEmployer Street AddressCityZipHave you ever been convicted of a crime?

Yes

Note: A conviction does not necessarily prevent participation in the Community Exchange program. If yes, please explain:

Do you smoke?

Yes

NoDo you object to being paired with someone who smokes?

Yes

NoDo you have any medical conditions or limitations we should know about?

Yes

If yes, please explain:

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Amutual sharing of everyday services

Community

Exchange

Columbia

Emergency Contacts

Please provide contact information for two personsthat can be notified in case of emergency.Members under the age of 18 must list parent/legal guardian as emergency contact.

Last NameFirst NameMIStreetCityZipTelephoneCell PhoneLast NameFirst NameMIStreetCityZipTelephoneCell Phone

Reference

Please provide information for two people who are not related to you that we may contact for a reference

Last NameFirst NameMIStreetCityZipTelephoneCell PhoneLast NameFirst NameMIStreetCityZipTelephoneCell Phone

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Service Opportunities

I have the following special skills, hobbies, interest etc.I am willing to provide services for people with the following disabilities/conditions.Check all that apply.

Stroke related handicaps

Alzheimer’s disease

Visual impairment

Hearing impairment

Mental disabilities

HIV/AIDS

Limited/poor mobilityOther, please list

I am interested in providing the following services: Check all that apply.

Personal/Individual Care

Respite

Social Stimulation

Reading/Writing