I.
| Contact Information
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| | First Name: | | Date: | |
| | Last Name: | | | |
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| | Address: | |
| | Home Phone: | | | |
| | Best Time To Call: | | | |
| | Email: | * required |
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| | Emergency Contact: | |
| | Relationship: | |
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| | References: (only one may be a relative; list names, phone number w/area code, and email address) |
| | 1. | 2. |
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| | Background Check: (Every volunteer is subject to a background check as Hillview does not
accept volunteers with any cases of theft or abuse.) |
| | First Name: | | Middle Name: | |
| | Last Name: | | Birthdate: | |
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II.
| This section for college students only.
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| | School: | |
| Major: | |
| | Class: | |
| | Hours: | |
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III.
| Frequency with which you wish to volunteer. (check preference)
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| | | Weekly (1,2, or 3 days) | | Monthly |
| | | Every Other Week | | Weekends Only |
| | | Other |
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IV.
| Time Preference/Skills/Abilities. (check preference)
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| | | Mornings: 9:00 am - 1:00 pm |
| | | Afternoons: 1:00 pm - 4:00 pm |
| | | Evenings: 6:00 pm - 8:30 pm |
| |
ALL VOLUNTEERS MUST GO THROUGH A 1-HOUR ORIENTATION SESSION.
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| | Days of the Week Preferred: |
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Any skills, hobbies, or previous experiences you would like to share: |
| | |
| | Any physical limitations: Yes No
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| | If yes, please explain:
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V.
| Possible Areas of Work Preference (Please mark your preferences.)
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Help with Parties
Provide Instrumental Talent
Provide Vocal Talent
Help In Making and Putting Up Decorations
Taking Residents for Walks/Rides/Outings
With Staff Without Staff
Transporting Residents To Activities
Helping To Prepare for Special Events (Christmas, Halloween, Valentines, etc)
Book Cart (Distributing Books/Magazines/Puzzles)
Play Music/Read/Simple Games for Room Bound Residents
Help With Programs for Low Functioning Residents (Creative Stimulation, Lounge Program)
Work with the Resident Rooms
Teach a Special Talent (Drawing, Knitting, etc)
Assist During Craft Projects/Woodworking
Friendly Visits to Residents Rooms
Letter Writing
Outdoor Gardening
Assist Exercise Group
Ladies Fingernail Painting
Bulletin Board Ideas
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By submitting this form, I understand that it is my responsibility to keep confidential any information I learn about the residents and/or their family, and that violating confidentiality is cause for immediate dismissal. |
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