Individual Application Form

This information will be stored in a secure database for the exclusive use of Timebanks of Puget Sound and will be used solely for the purposes of processing your application. PLEASE NOTE: The form is long, so we recommend you review what you will need to enter before you start or download a hardcopy form for reference. - Thanks!*

Today's Date

First Name*

Middle Name

Last Name*

Preferred Name

Other Names you are known by/Maiden Name

Date of Birth*

Gender*

Male
Female

Home Phone

Cell Phone

Preferred Phone

Cell
Home

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Which neighborhood/community timebank will be your home timebank?*

Eastside Timebank
Mercer Island Timebank

How did you hear about the timebank?

A friend told me
I saw a poster or brochure
I read it in a newspaper or blog
I learned about it from an organization or agency
I happened on it on the Internet
Other

Do you need an Online Partner to help you connect to the timebank on the Internet?

Yes
No

Are you interested in being an Online Partner to help a member without Internet access?

Yes
No
No, I don't have Internet access.

List 2 skills/services you might want to OFFER to other members.*

List 2 services you might want to RECEIVE from other members

Are there other timebank members in your household? If so, please share their names & relationships, so we can match up your records as a household. Additional names may be emailed to join@tbanks.org

Do you have any special needs, mobility issues, physical, mental or emotional limitations, medical conditions, or allergies that we should know about?

EMPLOYMENT: Current Employer (if applicable)

Employer's Phone

Employer's Address

Position/Title

Dates of Employment

VOLUNTEER HISTORY, Please provide the Organization Name(s), Position/Title, Duration of Volunteering (dates)

BACKGROUND CHECK - We require a background check for all members.*

Yes, I am willing to have a criminal background check.
No, I don't want a background check. I understand my application will not be processed until I resolve this. I will contact the administrator at join@tbanks.org

JUSTICE SYSTEM HISTORY - Omissions or misrepresentation of information on your application may disqualify you from participation in the timebank. "Yes" answers to questions will not necessarily disqualify you from participation. ----- Have you ever been convicted of a crime?*

Yes
No
That depends on what you mean.

If "Yes" or "That depends" please explain.

Have you ever had findings made against you in any civil adjudicative proceeding (e.g., involuntary commitment for mental illness, etc.)*

Yes
No

If “Yes,” please explain

Have you ever had a court order issues against you?*

Yes
No

If "yes" please explain and provide a copy of the order or the reference number.

RESIDENTIAL HISTORY - List the cities and states where you have lived over the past seven (7) years. Provide the City, the State, and the years. Start with the most recent residence, and please put one city and state per line:*

2nd most recent residence - City, State & years there.

3rd most recent residence - City, State & years there.

4th most recent residence - City, State & years there.

5th most recent residence - City, State & years there.

Earlier residencies - City, State & years there.

REFERERENCES - PERSONAL, PROFESSIONAL OR VOLUNTEER: Please list 2 references not related to you. Provide the Name, phone number, and email address for each reference, as well as your affiliation, position, or that person's relationship to you. Reference 1:

REFERENCE 2: Please provide the Name, phone number, and email address for each reference, as well as your affiliation, position, or that person's relationship to you. Reference 2:

RELEASE OF LIABILITY & MEMBERSHIP AGREEMENTS - I understand that the references, employers and volunteer organizations I have provided may be contacted and that Timebanks of Puget Sound may do a background check on applicants.*

YES
NO, I understand my application will not be processed further.

I consent to the release of all relevant information concerning my ability and fitness to participate as a timebank member.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I understand that, as a timebank, we offer neighborly services to each other. Members provide services to the best of their ability and do not guarantee their work. I understand that my neighborhood/community timebank and Timebanks of Puget Sound are coordinating agencies only and cannot guarantee the performance of anyone who is referred, and is not responsible for the services performed.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I understand that expenses for any materials used will be the responsibility of the recipient, and expenses will be agreed upon before the service is delivered.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I agree to only exchange lawful services through the timebank.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I understand that Timebanks of Puget Sound cannot be held responsible for any injury to persons or damage to property experienced while involved with the program. The applicant hereby agrees to hold Timebanks of Puget Sound, as well as its employees and/or agents harmless from any and all claims or liabilities for any activities performed by a timebank volunteer.

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I agree to take responsibility for any accident or injuries that I might suffer while on property owned or rented by any timebank member and waive any claim against that member.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I assume complete responsibility for the supervision and safety of my family members, including children, and take responsibility for any damage or accident in which my family members may be involved.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I understand that there will be immediate termination of membership of any member who harasses, harms, or interferes with any other timebank member or the Timebanks of Puget Sound organization.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I agree to refer any complaints or concerns to Timebanks of Puget Sound and to refer any disagreements with another timebank member to my neighborhood/ community timebank.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I agree that if I use my personal vehicle in rendering volunteer service through my timebank, I will, in accordance with Washington law, arrange to keep in effect legal automobile liability insurance covering bodily injury and property damage.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I pledge not to reveal the password to or contents of Timebanks of Puget Sound member database, and I will use reasonable care to protect the password.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I have read the Member Policies document and agree to the terms.*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

I agree to be held to the standards expressed in the Timebanks of Puget Sound Code of Conduct. http://tbanks.org/code-of-conduct/*

I AGREE
I DO NOT AGREE, I understand my application will not be processed further.

DEMOGRAPHIC INFORMATION: Timebanks of Puget Sound sometimes applies for grants. Often these applications require that we provide general demographic information about those we serve, but never connected with your name or address. Please supply as much information as you are comfortable with. We will only use it, aggregated with others, for us to apply for grants or to report to granting agencies. 1. GENDER

MALE
FEMALE
TRANSGENDER

AGE

Homeless?

YES
NO

Refugee/Immigrant

YES
NO

Limited English Proficiency

YES
NO

Disability

YES
NO

Household Composition

Single Live Alone
Single Head of Household with Children at home
Couple Head of Household, No Children at home
Couple Head of Household with Children at home

Household Income

Past or present US uniformed service, military or other?

YES
NO

Spouse or Partner of person in active uniformed service?

YES
NO

Minor dependent of active uniformed service member?

YES
NO

Ethnicity/Race

Reserved

Mail address @ Contact Us or bring your check to an orientation.

Anything you would like to add? Please enter, here.

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Individual Application Form

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