Consumer Information Sheet

Below is the Consumer Information Form that helps us match your needs with our services based on availability.

If you prefer to complete the form in a Word document and mail it in, click here. You may also call 540-899-8847 to make arrangements for someone to fill out this application by phone. Otherwise, continue below.

These questions are designed to be as non-invasive as possible. The primary purpose for asking these questions is to make the best possible match between you and a volunteer.

Personal Information

Check only one option below:

Volunteer Reader Options

If you want a volunteer reader, select the following options you want the volunteer to perform:

Health Related Concerns

These questions are designed to prevent VFB from assigning you a volunteer who is not an appropriate match because of health related concerns. For example, if you live in a fourth floor walk up apartment, VFB will not send you an elderly volunteer who has difficulty climbing steps unless the two of you agree upon a mutually accessible meeting place.

Do you have (check all that apply).

Shopping Assistance Options

If you want a volunteer to provide shopping assistance, check all that apply.

Is it within walking distance of your house?

Is it accessible by public transportation?

If you use a check to purchase groceries, do you want your volunteer to write it for you?

If you have a dog guide, will he or she accompany you and your volunteer when shopping?

Do you want your volunteer present when you unpack the groceries so he or she can identify items and help you label them?

Do you want your volunteer to help you shop for any of the following items? Check all that apply.

Do you want him or her to help you coordinate what you purchase with other items in your already existing wardrobe?

Questions for Everyone

How often do you want your volunteer to come?

Does it matter whether your volunteer is a male or a female?


Is your home near public transportation?






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