Program Volunteer Application Please, complete each of the following fields for the Program Volunteer application. When finished, please select the “Submit” button. Program Volunteer Application Name * First Name Last Name Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone Number * Best number to call (###) ### #### Secondary Phone Number (###) ### #### Email * How did you hear about this volunteer opportunity? Scheduling The Program Director will email volunteers mid-month to verify volunteer availability for the following month. Because mid-shift transitions can be confusing for participants, we are asking program volunteers to stay for the entire shift if possible–from 9:45am-2:10PM–which includes time for a daily briefing, room setup, and room breakdown. However, we understand this isn’t possible for all individuals. Please select from the following options: You may select more than one option Every Monday from 9:45am to 2:10pm (full shift) Every Monday from 9:45am to 12:10pm (early shift) Every Monday from 12pm to 2:10pm (late shift) Every Wednesday from 9:45am to 2:10pm (full shift) Every Wednesday from 9:45am to 12:10pm (early shift) Every Wednesday from 12pm to 2:10pm (late shift) Occasionally from 12-1pm on a Monday or Wednesday to prepare, serve, and clean up after lunch. I can't commit to a regular weekly schedule but am willing to help occasionally If you can't commit to a weekly schedule, how many times a month are you willing to volunteer? Personal History Hometown Other places lived Favorite pastimes Current and/or former occupations Tell us about any previous volunteer experience Do you have any special expertise you’d like to share with the Club (arts, fitness, admin, hospitality, etc)? Do you have personal experience interacting with, living with, caregiving for, or in any way spending time with an individual with dementia? If so, please explain below: Why would you like to volunteer for the Nelson Enrichment Club? Do you have any questions or concerns about volunteering at the Club? If so, please explain below: Please describe any other skills or life experiences that may be relevant to the volunteer position: References Reference #1 Name First Name Last Name Reference # 1 Phone Number (###) ### #### Relationship to you Reference #2 Name First Name Last Name Reference #2 Number (###) ### #### Relationship to you Reference #3 Name First Name Last Name Reference #3 Phone (###) ### #### Relationship to you Consent to background check Full Name Social Security Number I, the undersigned, hereby authorize Here to Stay Wintergreen and/or its authorized agents to conduct a background check as part of my Volunteer application. This background check may include, but is not limited to, the following: criminal records check; personal and professional references check; professional licenses and certifications check; motor vehicle records check. I understand that the information obtained will be used for the purpose of evaluating my suitability as a Volunteer. I understand that all information obtained will be kept confidential and will not be shared with any third parties except as necessary to conduct the background check. I release Here to Stay Wintergreen and any person or entity which provides information pursuant to this authorization from any and all liabilities, claims, or lawsuits in regard to the information obtained from any and all of the above-referenced sources. Notice to Applicants Under the Fair Credit Reporting Act (FCRA), you are entitled to a copy of any report obtained by Here to Stay Wintergreen. Should you wish to receive a copy, please request it in writing. Signature Date MM DD YYYY Volunteer Agreement & Liability Waiver I, _____________________________________, agree to the following regarding my role as a Volunteer for the Nelson Enrichment Club: 1. The Nelson Enrichment Club has provided me with a copy of the Policies and Procedures Manual, and I understand the contents and agree to adhere to all policies relevant to me. 2. I agree to communicate with the Lead Volunteer or Program Director in a timely manner if I have any questions or concerns about fulfilling my responsibilities or about the safety of any Members or Volunteers in the program. 3. I agree to actively engage with Members and program activities for the full length of my shift. 4. I agree to ensure the physical and emotional safety of Members by applying the skills and techniques learned through Volunteer training materials, meetings, and from feedback from the Program Director. 5. I agree to attend Volunteer trainings and meetings to the best of my ability. 6. I agree to communicate promptly with the Program Director regarding all scheduling matters, and to notify the Program Director in a timely manner if I will be absent for my scheduled shift(s). 7. I agree to protect and uplift the dignity of each Member and fellow Volunteers, and to maintain the confidentiality of all information pertaining to any Member, non Member, Volunteer, or other individual associated with the Nelson Enrichment Club. 8. I acknowledge that, as a Volunteer, I am not an employee. I understand that I will not be paid for any work that I perform. 9. I acknowledge that I am volunteering at my own risk. I fully and forever release and discharge Here to Stay Wintergreen and Rockfish Presbyterian Church, and their officers, employees, volunteers, agents and successors, from any loss, cost, damages or other liability which I may incur in the course of my volunteer work. Your signature below acknowledges your acceptance of this agreement and liability waiver. Full Name Signature Date MM DD YYYY Thank you!