Client Application – GVSS

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Home
About
Volunteer
- Youth Volunteer Application
- Adult Volunteer Application
Client
- Service Request
- Client Application
Equipment Loans
Donate

Home
About
Volunteer
- Youth Volunteer Application
- Adult Volunteer Application
Client
- Service Request
- Client Application
Equipment Loans
Donate

Home
About
Volunteer
- Youth Volunteer Application
- Adult Volunteer Application
Client
- Service Request
- Client Application
Equipment Loans
Donate

Fill Out Your
Client Application
Here!

If you would prefer to fill out a hardcopy application, click here to download the application. Please return the completed application to GVSS at 404 SE 2nd St., Suite 100 Grimes, IA 50111.

GVSS can only serve Grimes, Iowa residents. I confirm I am a Grimes resident.

Yes

How did you hear about GVSS?

Internet Search Website Social Media Friend Family School Other

First Name

Last Name

Date of Birth

Are you a Veteran?

Yes No

Gender

Male (he/him) Female (she/her)

Please check your age bracket:

Under 21 21-40 41-60 61-80 81+

Please check the 'best fit.'
Martial Status:

Single Married Widowed

Please check any that apply.
I use a:

Cane Walker Wheelchair Transport Chair

Please check your current living situation:

Alone, Unassisted Alone, With Assistance With Family With Friend(s)/Roommate(s) With Spouse/Partner Assisted Living Nursing Home

Email

Home Phone Number

Cell Phone Number

How would you prefer to be contacted?

Text Email Home Phone Cell Phone

Address

City

Zip Code

Emergency Contact Information:

Emergency Contact First & Last Name

Emergency Contact Address

Emergency Contact Phone Number

Emergency Contact Relationship

Please answer the following truthfully. It will help GVSS better pair you with volunteers.

Type of service(s) requested:

Transportation Delivered groceries, medications, books Personal assistance Simple handyman work Yard work Snow removal Borrow Durable Medical Equipment (DME)

Are you able to get in and out of a pickup truck or SUV?

Yes No

Can you get in and out of a car with minimal assistance?

Yes No

Do you need assisstance walking to the door?

Yes No

For pickup of groceries, medications, library books, etc, do you need:

Regular Trips Trips As Needed Service NOT needed

Would you need help putting groceries away?

Yes No

Please list yard work services needed:

None One-time Service Regularly Scheduled Service Raking Mowing Snow Removal

Please let us know what you have available for our volunteers to use:

Mower & Gas Rake Leaf Blower Lawn Bags Snow Blower & Gas Snow Shovels

Please list any handyman services you need:

Please acknowledge the following:

I understand that the volunteer will only be there to assist me. Any cost of medical appointments, grocery shopping, or supplies for handyman service or yard work will need to be paid by me.

Yes

I hereby grant permission to GVSS to take and use pictures and video of me in order to promote their services available in the community.

Yes

If accepted as a client, I will proved 7 days advanced notice when requesting a trip or client service.

Yes

I acknowledge that GVSS volunteers are only required to make 3 attempts to confirm a service before it is cancelled.

Yes

I have read and agree to GVSS Client Policies and GVSS Client Liability and Release

I agree and understand that by typing my first and last name below, I am providing my electronic signature on this document, and it is the legal equivalent of my manual/handwritten signature.

404 SE 2nd St, Suite 100 Grimes, IA 50111
(515) 986-5355
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Volunteer
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Client
- Service Request
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Donate

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