Participant Application

Thank you for your interest in becoming an SCNOVA Participant. Participant is the term we use for the older adults we serve. If you want to receive services such as Transportation, Food Delivery, Friendly Caller, Friendly Visitor, and Minor Home Repair, please first complete a Participant Application. You do not need to complete a participant application for Caregivers Support, Health & Wellness classes, or Social Events – although all our participants can avail themselves of these services.

* Participants must be able to get in/out of volunteer driver’s vehicle independently. We are unable to accommodate/transport wheelchairs.

There are two ways to complete a Participant application:

1. Fill out the online form here ➡️ (preferred).
   "*" indicates required fields

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   This field is for validation purposes and should be left unchanged.

   Application Date*

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   Please complete the rest of the Application with only the Applicant's information

   Participant Applicant Name*

   First Last

   Applicant Birth Date*

   Gender*

   Male

   Female

   Prefer Not To Answer

   Marital Status*

   Single

   Married

   Divorced

   Widowed

   Life Partner

   Primary Language*

   Residence Address*

   Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

   Cell Phone*

   Home Phone*

   Email*

   Text Messaging

   Yes

   No

   How did you hear about the Shepherd's Center of Northern Virginia?

   Referred By:

   Congregation Affiliation:

   Which Shepherd’s Center services are you interested in? Choose as many as you wish.*

   Transportation

   Friendly Caller

   Friendly Visitor

   Handy Helper

   Please indicate which of the following apply to you (or the participant if completing this form for someone else). This information helps our volunteer drivers provide a safe and comfortable ride. Participants must be able to independently get in/out of the volunteer driver's car. Drivers are unable to assist participants in wheelchairs even with a companion.*

   I use a cane

   I use a walker

   I use a rollator

   I have limited vision

   I have limited hearing

   I have balance concerns

   I have NO cognitive, mobility, visual or hearing limitations.

   Will a companion be accompanying you on all rides? If yes, please complete the Companion Application below.

   Yes

   No

   Are you a Veteran?*

   Yes

   No

   if yes, which branch?

   What is your living arrangement?*

   SelectAloneSpouseFamilyFriendOther

   Household Size?*

   Please enter a number from 1 to 4.

   What is your 1 person household annual income?*

   SelectWhat is your 1 Person annual income?Less than $32,500Less than $54,150Less than $68,500More than $68,500Decline to report

   These questions are used anonymously for grant reporting. Answers will not determine your eligibility for a ride.

   What is your 2 Person household annual income?*

   SelectLess than $34,340Less than $57,400Less than $74,800More than $74,800Decline to report

   These questions are used anonymously for grant reporting. Answers will not determine your eligibility for a ride.

   What is your ethnicity?*

   SelectHispanic/LatinoNot Hispanic/LatinoDecline to state

   What is your race?*

   Caucasian

   Black/African American

   American Indian/Alaskan Native

   Asian

   Hawaiian/ Pacific Islander

   Middle Eastern

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   Emergency Contact

   Emergency Contact Name:

   Phone:

   Email

   Relation to Applicant

   Emergency Contact Address

   Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

   Are you completing this form for yourself, or for someone else?*

   Myself

   Someone Else

   If you are completing this application for someone else, what is your name?*

   First Last

   Phone*

   Email

   Consent*

   I agree to the New Participant Agreement.

   Please read the information below which includes eligibility requirements and guidelines for all new participants.
   
   Eligibility Requirements for Participant Services
   Adult must be 50+ years of age or older
   Must live in Oakton-Vienna-Reston-Herndon-Great Falls (we do handle a small portion of Fairfax, and will notify potential participants whether they are out of the service area during the initial call to our office)
   Must be ambulatory; use of a cane or walker is acceptable.
   
   Guidelines- for Free Transportation Service
   Office hours are Monday-Friday, 10am – 4pm. You must speak to a SC Office Volunteer for your ride request to be processed by calling: 703.281.0538.
   
   When making an initial contact allow at least THREE business days before your appointment. (Exceptions may be made in the event of an emergency at the discretion of the office staff).
   
   Remember: No ride is ever guaranteed, and same day service is not available.
   
   Provide the following information when making a service request:
   Full name, address, and phone number of the doctor, therapist, or trip destination
   Time, date and duration of the appointment.
   For most medical/dental appointments, you may be charged if you do not cancel within 24 hours of the appointment. We will try to let you know the day before if no driver has picked up your request. However, if you have not heard from a driver or SC Office Volunteer the day before your requested date, you should make other arrangements for transportation.
   
   If you have a Monday appointment the SC Office Volunteer will call you on Friday if no volunteer has picked up the ride.
   
   It is up to the discretion of the driver whether any additional stops can be made. Participants are limited to a maximum of 3 rides drives per week, depending on driver availability.
   
   All arrangements for your transportation are to be made through the Shepherd’s Center. Call the office immediately if your appointment is changed or cancelled.
   703.281.5038. Participants are not to call volunteers at home unless to convey a cancellation of a drive after office hours.
   Participants are responsible for paying any tolls or parking fees.
   Drivers will take participants to appointments in most areas in Northern Virginia.
   If an appointment or ride is cancelled, participants should contact the office to let us know.
   
   Requirements for Medical Transportation
   
   Please bring a current listing of all medications, including dosage amounts.
   Have the contact information for your primary care physician.
   Have Emergency Contact Information on hand.
   
   Services Provided
   
   Medical and Companion Transportation (groceries, hairdresser, banking, etc.)
   Handy Helpers
   Friendly Callers
   Friendly Visitors
   Veterans Initiative
   Special Educational and Social Events
   
   Please call the office or check the website for details on each service.
   
   
   Remember everyone who performs a service for the Shepherd’s Center is a Volunteer. Please be considerate of their time and treat them with the same courtesy that you expect and deserve.
   
   Lastly, thank you for your cooperation with these guidelines. If you have any questions or concerns about them, please contact the office. We welcome you as a new participant of the Shepherd’s Center of Northern Virginia and we look forward to serving you in the future!

   Do you have any comments or questions we can address when we contact you?

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   Companion Transportation Form

   For insurance and safety purposes, Shepherd's Center of Northern Virginia must keep a record of all occupants in our volunteer drivers' vehicles.

   If you will accompany a participant on rides, please complete this form and return it with the participant's application.

   Name

   First Last

   Address

   Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country

   Birthday

   Month

   Day

   Year

   Name of Participant you will accompany on rides:

   Relationship to the participant:

   Spouse

   Family Member

   Friend

   Health Care Provider

   Name of employer if you are a Health Care provider:

   Companion's Emergency Contact (separate from participant's):

   Companion's Emergency Contact Phone Number

   Country Phone Number

   Companion's Emergency Contacts Email

   Post Title

   Previous Submit

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2. Download the Participant Application HERE, complete, sign, and return application one of two ways:
   1. email to: scnovaops@scnova.org
   2. by mail:  Attn: Data and Operations, SCNOVA, 111 Church St NW, Suite 202B, Vienna, Virginia 22180

*Please complete every portion of the application. Incomplete applications WILL NOT BE ACCEPTED.

*Please remember in order to become a participant of the Shepherd’s Center of Northern Virginia you must reside in: Oakton, Vienna, Dunn Loring, Merrifield, Reston, Herndon, Great Falls or Fairfax (north of rt. 50), Virginia.

*Zip codes we service are: 22031, 22033, 22124, 20171, 20170, 20190, 20191, 20194, 22180, 22182, 22181, and 22027.

*If you have questions or need assistance, please contact our office at (703) 281-0538.