VOLUNTEERS FOR THE HOMEBOUND & FAMILY CAREGIVERS

1515 N. Federal Hwy. Suite 214

Boca Raton, FL 33432

(561) 391-7401 (561) 416-7213 - Fax

info@boca-respite.org www.boca-respite.org info@aacy.org www.aacy.org

VOLUNTEER APPLICATION

Social Security # ____________________________ Date ______/______/______

Name: __________________________________________________________________________________

Title First Last

Address: _________________________________________________________________________________

City: _______________________________ State: ____________ Zip: __________________

Phone(s): Home (____)_______________ Work (____) ______________ Cell (____) _________________

E-Mail Address: ____________________________________________

Date of Birth _______/______/_______ Male _____ Female _____

Volunteer/Caregiving Experience:

___ None ____ RSVP ____ Previous volunteer experience ____ Volunteer leadership experience

Please indicate volunteer/caregiving experience below:

Organization	In What Capacity?

Are you affiliated with a local church/synagogue? _______ Which one? ______________________________

Are you employed? Y / N ___ Full-time ___ Part-time ___ Retired ___ Student

Employer Name: _________________________________________ Phone: ______________________

Address _________________________________________________________________________________

Do you have any licenses, degrees or skills that might be relevant to a special assignment?

________________________________________________________________________________________

What languages do you speak? ___ English ___ Spanish ___ French ___ Hebrew ___ Other ___________

Please list two personal references (other than relatives):

1. Name: __________________________________________ Phone: ______________________

Address: __________________________________________________________________________

2. Name: __________________________________________ Phone: ______________________

Address: __________________________________________________________________________

How did you hear about us? _________________________________________________________________

Please check the service areas that you would be most interested in:

____ Child Activities ____ Clerical/Office/Bookkeeping ____ Community Relations

____ Congregational Outreach ____ Corporate Outreach ____ Editing/Writing

____ Event Planning ____ Friendly Visiting ____ Fund Raising ____ Life Skills Mentoring ____ Marketing ____ Meal Preparation ____ Public Speaking ____ Reading/Writing ____ Respite Care

____ Shopping/Errands ____ Small Group/Counseling ____ Special Events

____ Telephone Reassurance ____ Transportation ____ Web Development

____ Yard Work/Home Repair ____ Other (Specify) ____________________________________

What is your preference for assisting various age groups?

____ Any Age ____ Children ____ Teens ____ Adults ____ Seniors

Please indicate the hours and the days you are available to volunteer:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evening

Have you ever been charged or convicted of a felony or misdemeanor? ___ Yes ____ No

If yes, please state full details: _______________________________________________________________

Do you have a car with adequate insurance ($100,000/$300,000 limit) on personal auto insurance liability?

____ Yes ____ No How far are you willing to drive? ___________ miles

License expiration date _________ License # ____________________________________ State __________

Auto insurance expiration __________ Company _________________ Policy # ______________________

Do you have any physical limitations or medical conditions that need to be considered when making assignments? ____ Yes ____ No

If yes, please explain: ______________________________________________________________________

In case of emergency contact:

Name: _______________________________________________ Relationship: _______________________

Phone(s): ______________________________________________

I hereby authorize VHFC to (a) verify all statements and references in this application and; (b) undertake a background check on me, including without limitation, the local, state and federal law enforcement agencies.

Volunteer Signature: _______________________________________ Date: _______________________

Parent/Guardian Signature __________________________________ Date: _______________________

(If applicant is under 18)

AGENCY/VOLUNTEER AGREEMENT

This Agreement is intended to indicate the seriousness with which we treat our volunteers. The intent of the Agreement is to ensure you of our deep appreciation of your services and is to indicate our commitment to do the very best we can to make your volunteer experience here a productive and rewarding one.

AGENCY

Volunteers for the Homebound & Family Caregivers, Inc. agrees to accept the services of: ___________________________________ (volunteer) beginning ____/____/_____ and we commit to the following:

To provide adequate information, education, and assistance for the volunteer to be able to meet the responsibilities of his/her position.
To ensure diligent supervisory aid to the volunteer and to provide feedback on performance.
To respect the skills, dignity and individual needs of the volunteer.
To be receptive to any comments from the volunteer regarding ways in which VHFC might mutually better accomplish its goals.
To make every effort to make the volunteer experience a rewarding one.

VOLUNTEER

I _________________________ (volunteer) agrees to serve as a volunteer and commit to the following:

I will perform my volunteer duties to the best of my ability.
I will adhere to VHFC rules and procedures, including record keeping requirements and confidentialities of VHFC clients.
I will meet time commitments or provide adequate notice so that alternate arrangements can be made.
I will not use illegal substances or smoke while volunteering with the agency, either at agency offices or in the home of a client.
I know of no reason, medical or otherwise, which prevent me from carrying out my assigned tasks.
I certify that all statements are true to the best of my knowledge.
I give permission to VHFC to verify all statements made and to perform a background check.

OATH OF CONFIDENTIALITY

Volunteers for the Homebound & Family Caregivers, Inc. has a commitment to protect the privacy of the individuals it serves. All representatives of VHFC, including volunteers, are bound by agency policy to protect the privacy of those receiving services. I agree not to discuss or disclose client and other agency information except with authorized agency personnel.

Volunteer Signature _____________________________________ Date: _______________________

Staff Witness Signature: __________________________________ Date: _______________________

FOR AGENCY USE ONLY:

Date of Interview _______ Interviewed By: ____________________________________________

Date of Orientation _______ Orientation Conducted By: ____________________________________

Date Background Verification/Fingerprints Received ______

Comments: _______________________________________________________________________________

________________________________________________________________________________________