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Personal Information
Name
Address
City
State
ZIP
Home Phone
Work Phone
Cell Phone
Email
Preferred Method of Contact
Church Affiliation (Optional)
Birthdate
Emergency Contact Name & Phone
 
Interest, Skills and Experience
Job(s) interested in
Knowledge or skills you want to develop or demonstrate
Occupation (former or present)
Do you have previous volunteer experience? If so, what?
Do you have previous experience working with Seniors? If so, what?
Background Verification
Have you ever been convicted of a felony?
Have you ever been charged with neglect, abuse or assult?
Do you have any physical limitations or are you under any treatment which might limit your ability to perform certain types of work? If yes, please explain
Is this volunteer experience for service hours?
If yes, how many hours
For what organization?
Times Available (check all that apply)
References Please provide two non-family references that we may contact:
Name Relation to you Address Daytime Phone
How did you hear about us?
I would prefer to volunteer in:
Additional Comments:
Confidentiality
As an Augustana volunteer, I recognize that any information and documents I review in the course of meeting my volunteer responsibilities are to remain in the strictest confidence. No information may be released or discussed except as is necessary for fulfillment of my volunteer responsibilities. Sharing of information, documents, and/or photos requires signed releases for approval of Augustana Care. Failure to comply with the Confidentiality Agreement will result in immediate termination.
Certification
I agree to adhere to the confidentiality policies of Augustana Care, and I declare my answers to the questions of this application are true. By submitting the information above, I give Augustana Care permission to check my references and information provided.
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Copyright © 2012 Emerald Crest Senior Assisted Living Memory Care | Last updated December 15, 2010