Volunteer application - DaySpring Villa

Personal Information

Prefix*

First name*

Middle name

Last name*

Birthdate*

Address*

Street Address City State ZIP Code

Home phone*

Email

.

Are you a Christian?

Where do you attend church?

.

Employer Information

Employer name

Phone

Position

.

References (list two that are not related to you)

Name

First and last

Phone

Relationship

Name

First and last

Phone

Relationship

Have you been convicted of crime?

If yes, please explain.

.

Education

Highest level of education completed

High School

Name/City/State Years Completed

College

Name/City/State Diploma Degree

Graduate

Name/City/State Diploma/Degree

Other

Name/City/State Years Completed

Special skills, training and certifications

Foreign Language(s)

.

Availability

Day(s) preferred to volunteer

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Times preferred to volunteer

Tell us about yourself, primary interests, hobbies:

Why are you interested volunteering with our agency specifically?

.

Health

Hospital preference

Emergency contact*

Emergency phone*

Pertinent health information

.

Volunteer positions are subject to a background check

In signing this application, you are giving authorization for DaySpring Villa to investigate your background, and take a picture of your person that will be kept in your volunteer file. Thank you.*

Signature Date

Are you over 18 years of age?*

Must be accompanied by an adult if under 18 years.

Adult volunteer signature

STATEMENT OF CONFIDENTIALITY

As a staff member of Day Spring Villa, or a student, volunteer, or speaker affiliated with DaySpring Villa, I will not divulge any information that comes to me through the carrying out of my assigned duties, program, or assignment while at this facility. This shall include: Not discussing any specific guest, or any information pertaining to any specific guest, with anyone (even including my own family) who is not directly working with said guest. Not discussing information pertaining to any guest any place it can be overheard by anyone not directly working with said guest, especially other guests. Not mentioning any guest's name or admitting, directly or indirectly, any person named is a guest, except to those authorized to have this information. Not describing any behavior which I have observed, heard, or learned through my relationship as a staff/student/volunteer/speaker affiliated with DaySpring Villa, except to those authorized to have this information. I will not contact any individual or agency outside this facility to get personal information about an individual unless a Release of Information Form has been signed by the guest or guardian of the guest.

YOUR NAME BELOW IS YOUR SIGNATURE OF AGREEMENT*

Signature

Date

Name

This field is for validation purposes and should be left unchanged.

DAYSPRING VILLA VOLUNTEER APPLICATION FORM

STATEMENT OF CONFIDENTIALITY

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