Form Center

2. Town of North Kingstown

   Department of Senior and Human Services
   P.O. Box 313
   44 Beach Street
   North Kingstown, RI 02852

3. Expiration Date:

   December 31, 2025

5. First Name*
6. Last Name*
8. Cell Phone Number*
9. Email Address*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Date of Birth*

    Month Day, Year

18. Marital Status:*

    1. Single

    1. Married

    1. Widowed

    1. Divorced
20. Gender:*

    1. Male

    1. Female
22. **Ethnic Background*

    1. Caucasian
    2. Hispanic

    1. Middle Eastern
    2. Native American

    1. Asian American
    2. African American

    1. Other

    
    

    
    

    **Ethnic background required by State and Federal Agencies. All information retained as confidential records by Town of North Kingstown Senior and Human Services.

24. Education / Occupation
26. Special Qualifications / Skills
28. Are you interested in volunteering for Beechwood?

    1. Yes

    1. No
29. Time and Availability
31. In case of emergency, please notify:
33. Contact 1
35. Name*
36. Relationship*
38. Home Number
39. Day Phone
40. Cell Phone*
42. Contact 2
44. Name
45. Relationship
47. Home Number
48. Day Phone
49. Cell Phone
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field