Contact Information
|
|
Date: |
xx/xx/20xx |
|
Name/Co: |
*
|
|
Email: |
*
|
|
Phone#: |
*
|
| Alternate#: |
|
| Address: |
|
| City / State / Zip: |
|
|
|
| Occupation: |
|
| Employer: |
|
| Other Experiences: |
|
| Previous Volunteer Experience: |
|
| Hobbies, Skills Special Interests: |
|
| Community Affiliations: |
|
|
|
| References: List two to three people that have known you
for longer than year (Excluding Relatives) |
|
|
| Name: |
|
| Address: |
|
| Phone: |
|
|
|
| Name: |
|
| Address: |
|
| Phone: |
|
|
|
| Name: |
|
| Address: |
|
| Phone: |
|
|
|
| Emergency Contact: |
|
| Relationship: |
|
| Phone: |
|
|
|
| Are you related to any employee and/or resident in this facility? |
|
| Please Specify Person: |
|
|
|
| How did you hear about our volunteer program? |
|
|
|
| Any Medical or Physical problems we should be aware of? |
|
| Please Specify: |
|
|
|
| List any felony and/or misdemeanor convictions, excluding minor
traffic violations: |
|
|
|
| Frequency with which you wish to volunteer: |
|
|
|
| Time Preference: |
|
|
|
| Length of time you wish to serve: |
|
|
|
| Day(s) of week preferred: |
|
|
|
| Do you wish to put a time limit on you volunteer commitment: |
|
| Other Please Specify: |
|
|
|
| Can you volunteer transportation for patients? |
|
|
|
| Do you speak a foreign language? |
|
| Please Specify Language: |
|
|
|
| Have you ever had a family member or friend in a nursing home? |
|
| Please Specify Home: |
|
|
|
Are there any skills drawn from previous experiences you would
care to use in volunteer work?
(Other Languages, Hobbies, work or volunteer experiences). Please Specify: |
|
|
|
| Select each Volunteer area of interest: |
|
|
|
| Additional Comments: |
|
|
|
|