NAME:
Other Names Used (Maiden Name, Nicknames):
ADDRESS:
CITY, STATE, ZIP:
WORK/OTHER PHONE#:
DATE of BIRTH (Optional): SOCIAL SECURITY# (Optional):
DRIVER'S LICENSE #(Optional):
IN CASE OF EMERGENCY, NOTIFY (NAME & PHONE #)
LANGUAGES SPOKEN:
EMPLOYMENT STATUS?
FULL TIME;
PART TIME;
RETIRED;
STUDENT;
DESCRIBE YOUR EXPERIENCES;
WORKING WITH THE ELDERLY
WITH NURSING OR ASSISTED LIVING FACILITIES,
AS A VOLUNTEER,
WHAT HOBBIES, INTERESTS, AND ORGANIZATIONS ARE YOU INVOLVED IN
ARE YOU CURRENTLY EMPLOYED BY OR ASSIST IN THE OPERATION OF A LONG-TERM CARE FACILITY:
IF YES, PLEASE DETAIL IN FULL
DO YOU HAVE A FAMILY MEMBER EMPLOYED BY OR CONNECTED WITH A BUSINESS INTEREST IN A LONG-TERM CARE FACILITY:
IF YES, PLEASE DETAIL IN FULL
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR
IF YES, PLEASE DETAIL IN FULL
AVAILABILITY; AT LEAST 2 HOURS EACH WEEK AT VARIOUS TIMES DURING THE WEEK? OTHER?
HOW DID YOU LEARN ABOUT THE OMBUDSMAN PROGRAM?
BRIEFLY DESCRIBE WHY YOU WANT TO BECOME A VOLUNTEER FOR THE OMBUDSMAN NURSING HOME PROGRAM
PERSONAL REFERENCE. (Name/Address/Ph#/Relationship)
PROFESSIONAL REFERENCE. (Work:Name/Address/Ph#)
DATE OF APPLICATION:
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