Special Session Volunteer Application Please, complete each of the following fields for the Special Session Volunteer application. When finished, please select the “Submit” button. Special Session 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? SPECIAL SESSION VOLUNTEERS Activities such as listening to music, making music, creative art projects, fitness classes, and pet therapy have been shown to be beneficial for individuals with dementia. Thus, special session volunteers fulfill the critical role of bringing fun, engaging, safe, and beneficial experiences to program participants. SCHEDULING Special sessions are scheduled during regular program hours of 10am-2pm, Mondays and Wednesdays. Length of time varies for special sessions, according to the activity and volunteer availability. Special sessions can be regularly scheduled (ie. every Monday, or the first Wednesday of the month); or, they can be scheduled occasionally, according to volunteer availability and the needs of the program. Please indicate your basic availability below, and the Program Director will be in touch for more specific schedule information. Please select from the following options: You may select more than one option I’m able to volunteer weekly. I’m able to volunteer 2-3x/month. I’m able to volunteer about 1x per month. I’m able to volunteer occasionally. Please let us know more about your schedule and availability: Personal History Please tell us more about the special skills or interests you’d like to share with program participants (ex: music, visual arts, crafts, fitness, yoga, dance, pet therapy, etc). Do you have any certifications and/or professional experience in this area? If so, please describe. Do you have any special expertise you’d like to share with the Club (arts, fitness, admin, hospitality, etc)? How much time do you think you will need in order to share your skill with program participants? 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: 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 Special Session Volunteer Agreement & Liability Waiver I,_______________________________, agree to the following regarding my role as a Special Session Volunteer for the Nelson Enrichment Club: 1. 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. 2. 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 special session. 3. 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. 4. 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. 5. 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. Volunteer Name Volunteer Signature Date MM DD YYYY Thank you!