Volunteer ApplicationVolunteer Application Volunteer Application First Name * Middle Initial Last Name * Preferred Name * Address * Address Line 2 City * State / Province / Region * ZIP / Postal Code * Country * Date of Birth * Sex * Male Female Phone Number * Notify in Case of Emergency First Name * Middle Initial Last Name * Preferred Name * Address * Address Line 2 City * State / Province / Region * ZIP / Postal Code * Country * Employment/Volunteer Experience Employer Name Position From * To * Employer Name Position From * To * Employer Name Position From * To * Hobbies, Skills, Talents, Special Interests, Special Training Volunteer for Outings Special Events Mail Distribution Letter Writing Calendar Activities Special Friend Activities of Daily Living Check all that apply Other Schedule Preferred Nearest Relative Nearest Relative Name Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Phone Number Relationship Have you performed volunteer services in a nursing facility before? Yes No If yes, where? Do you enjoy working with Senior Citizens? Yes No Do you have any relatives in this nursing facility? Yes No If yes, where? Have you ever had any relatives in a nursing faculity? Yes No If yes, where? Do you think nursing facilities provide needed services? Yes No If no, please make comments as to how services could be improved. Will you be willing to provide volunteer services to this facility? Yes No How many hours can you donate? Day Week Month On what days would you be available? Sunday Monday Tuesday Wednesday Thursday Friday Saturday Check all that apply What time of day would you be available? Morning Afternoon Evening Do you have any special talents you wish to share with our residents? Do you play any musical instruments? What types of services would you be willing to provide? (List in order of preference.) If selected to participate in our volunteer program, do you agree to abide by the rules and regulations established by this facility? Yes No If you are 17 years old or younger, please bring a permission letter from a parent or guardian Signature of Applicant Today's Date Activity Director Today's Date Captcha If you are human, leave this field blank. Submit