Member Application

Step 1 of 10 - About You

Step — About You

Let's get you connected to your community.

This application takes about 10–15 minutes. You can save your progress and return at any time — no rush at all.

! Filling this out for someone else? Use their information — not yours — for any question that says "you" or "your."

About You

How should we address you?

First Name Last Name

If different, please indicate your legal name here

Date of Birth

MM slash DD slash YYYY

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*Admin - Country(Required)

Address

Street Address Address Line 2 City State ZIP Code

Do you want to receive mail at a PO Box?

Yes

PO Box Information

PO Box Address City State ZIP Code

Step — Member Contact Details

How should we stay in touch?

Contact Details

Email Address

Mobile Phone

SMS Consent

A Little Help may occasionally send text messages to your mobile phone to communicate program and fundraising events. If you do not wish to receive text messages, including messages to confirm an activity request, or that a volunteer has accepted your request, please check the box below.

I do not want to receive any text messages from ALH

Do you want to add a home phone number?

Yes

Home Phone

Are you able to communicate by phone or email Independently?

I'm unable to communicate by myself.

To ensure we can provide the best possible support; our A Little Help team and volunteers need to be able to stay in touch via phone or email. In order for us to coordinate help effectively, it is necessary for our applicants to be able to communicate with our office and volunteers on their own. Because our process requires this direct line of communication, we are unable to move forward with your application at this time. However, we would be happy to reconsider your request in the future should your circumstances change.

Step — Personal Details

Tell us more...

Personal Details

Gender

Female

Male

Transgender

Nonbinary

Prefer not to say

Race identity

Other race identity:

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

What is your primary language?

If other, please specify here

Are you a veteran?

Yes

Are you currently employed?

Yes

I'm unemployed

I'm retired

Please share your past or present profession

Do you have interests or hobbies?

Reading

Playing cards / board games

Gardening

Writing

Art

Doing puzzles

Listening to music

Photography

Exercising

Sports

In a few words, tell us why you are applying today

Step — Your Health

Title Here

! All questions in this section apply only to the individual applying for ALH services, as identified in the previous section.

Your Health

Do you have mobility issues?

Yes

Which assisting tools do you use regularly?

Cane

Walker

Wheelchair

Other

Other mobility aid

Are you visually impaired / legally blind?

Yes

Do you use aid?

None

Cane

Guide dog

Other

Please provide additional details about your vision issues

Are you hearing impaired?

Yes

Do you use a hearing assistance device?

Yes

Please provide additional details about your hearing issues

Do you require an oxygen tank for assistance with breathing?

Yes

Are you personally living with the following?

Alzheimer's / Dementia

Parkinson's

Issues following a stroke

Brain or spinal injury

Bells Palsy

ALS

Other

Please specify:

Have you had injuries, hospitalization, diagnosis in the last 6 months?

Yes

Date of most recent injury / hospitalization

MM slash DD slash YYYY

If comfortable, please share details

Step — Living Environment

Tell us what it's like at home.

Living Environment

Is there a smoker in the household?

Yes

Are there pets in the house?

Yes

What type?

Cat

Dog

Bird

Other

Other types of pets

Technology

Do you use a smartphone?

Yes - Android

Yes - iPhone

Yes - not sure/other

Do you use a tablet?

Yes - Android

Yes - iPad

Yes - not sure/other

Do you use a computer?

Yes - Mac

Yes - PC

Yes - not sure which

Financial Situation

Please share your household monthly income

Do you receive Medicaid?

Yes

Step — Your Household

Title here

! Filling this out for someone else? Use their information — not yours — for any question that says "you" or "your."

Your Household

Are you currently

Single

Married / Domestic Partner

Widowed

Do you live with a spouse / partner?

Yes

Do additional people live in your home?

Yes

Step — Your Partner

Tell us about your partner.

! Filling this out for someone else? Use their information — not yours — for any question that says "you" or "your."

Your Partner

How should we address your partner?

Partner's First Name Partner's Last Name

Partner's legal name, if different from above

Partner's Date of Birth

MM slash DD slash YYYY

Your Partner's Contact Details

Partner's Email Address

Partner's Mobile Phone

SMS Consent

Do not send text messages to this phone number

Your Partner's Personal Details

Their Gender

Female

Male

Transgender

Nonbinary

Prefer not to say

Their past or present profession

Is your partner a veteran?

Yes

Your Partner's Physical Health

Do they have mobility issues?

Yes

Which assisting tools do they use regularly?

Cane

Walker

Wheelchair

Other

Other mobility aid

Are they visually impaired / legally blind?

Yes

Do they use aid?

None

Cane

Guide dog

Other

Please provide additional details about their vision issues

Are they hearing impaired?

Yes

Do they use a hearing assistance device?

Yes

Please provide additional details about their hearing issues

Do they require an oxygen tank for assistance with breathing?

Yes

Are they personally living with the following?

Alzheimer's / Dementia

Parkinson's

Issues following a stroke

Brain or spinal injury

Bells Palsy

ALS

Other

Please specify:

Have they had injuries, hospitalization, diagnosis in the last 6 months?

Yes

Date of their most recent injury / hospitalization

MM slash DD slash YYYY

If comfortable, please share details

Does your partner receive Medicaid?

Yes

Your Partner's Technology

Do they use a tablet?

Yes - Android

Yes - iPad

Yes - not sure/other

Do they use a smartphone?

Yes - Android

Yes - iPhone

Yes - not sure/other

Do they use a computer?

Yes - Mac

Yes - PC

Yes - not sure which

Step — Household Member

Who lives with you?

! Filling this out for someone else? Use their information — not yours — for any question that says "you" or "your."

Household Member

How should we address this person?

First Last

What is their relationship to you?

Other:

Gender

Female

Male

Transgender

Nonbinary

Prefer not to say

Date of Birth

MM slash DD slash YYYY

Email Address

Mobile Phone

SMS Consent

Do not send text messages to this phone number

Add another household member

Household Member 2

How should we address this person?

First Last

What is their relationship to you?

Please specify:

Gender

Female

Male

Nonbinary

Prefer not to say

Date of Birth

MM slash DD slash YYYY

Email Address

Phone number

SMS Consent

Do not send text messages to this phone number

Step — Emergency Contact

In case of an emergency.

Please provide the contact information below for at least one person outside of your household. You are welcome to share the name and number of a friend or relative who lives out of state. This information is only used in the rare case that we are unable to reach you after several attempts. We will contact this person in case of emergency.

! Filling this out for someone else? Use their information — not yours — for any question that says "you" or "your."

Primary Emergency Contact

Primary Emergency Contact:

First Name Last Name

This person is your

Sibling

Friend / Neighbor

Caretaker

Child

Grandchild

Parent

Other Relative

Their phone number

Their email

Add another emergency contact

Add a secondary emergency contact

Secondary Emergency Contact

Secondary Emergency Contact:

First Name Last Name

This person is your

Sibling

Friend / Neighbor

Caretaker

Child

Grandchild

Parent

Other Relative

Their phone number

Their email

Step — Agreement and Waiver

Last things...

You're so close.

! Filling this out for someone else? Use their information — not yours — for any question that says "you" or "your."

Agreement and Waiver

How did you hear about A Little Help?

Please specify:

Help spread the word about A Little Help — would you like a yard sign for your home?

Yes, I want a Yard Sign

No, I don't want a Yard Sign

Information for Respect Agreement

The only way A Little Help can operate is if there is mutual respect among our members, volunteers, and staff.

I understand that A Little Help is not solely a service provider but is also, and more importantly, a community. To that end, I will treat all volunteers and staff of A Little Help with respect and can expect such in return.

If accepted, A Little Help reserves the right to cancel my membership if I am in violation of this community agreement.

I accept

Waivers

A Little Help carries liability insurance, and all our volunteers and older adult members are protected in the State of Colorado by the Good Samaritan Law.

By signing your membership application, you release A Little Help, its officers, employees, agents, and volunteers from any and all liability, claims, and demands of whatever kind or nature for any action or inaction by the member that may result in property damage, personal injury, or death to you, or to any person entering upon your property, whether resulting from negligence or otherwise, and you will indemnify and hold harmless A Little Help, its officers, employees, agents, and volunteers from any liability resulting from any legal action you institute or any legal action taken against you, for any property damage, personal injury, or death or other loss resulting from the volunteer efforts by a participant in this program.

A Little Help reserves the right to utilize the contact information provided to share our mission with your contacts.

I agree

Signature

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*Admin - Timestamp

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*Admin - Added By

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*Admin - Contact Source