Volunteer

First Name*

Middle Initial*

Last Name*

Address*

City/State*

Postal Code*

Phone - Primary:*

Secondary (if applicable)

Email*

Occupation

Date of Birth*

Age

Best Time to Contact via Phone*

Volunteer Schedule*

One Time Volunteer

Long Term Volunteer

Unsure

Start Date*

ASAP?

Yes

Preferred Method of Contact*

Phone

Would you be interested in taking part of an email database that will update you on Advent Home Care Alliance and its upcoming events?*

Yes

How did you hear about Advent Home Care Alliance and its volunteer program?*

Why are you interested in volunteering?*

If you are looking for one-time/short term volunteer opportunities, which events are you interested in?*

How do you hope to benefit from this experience?*

Do you have any special skills which you have or could bring to the events?

Organization

Position/Major Responsibility

Dates of Service (yy/mm) From:

Dates of Service (yy/mm) To:

Please provide 3 references:

Name of Contact 1*

Phone Number of Contact 1*

Name of Contact 2*

Phone Number of Contact 2*

Name of Contact 3*

Phone Number of Contact 3*

Have you ever been convicted of a crime? (This does not include minor traffic offenses and/or convictions which have been sealed, expunged or statutorily eradicated.)*

Yes

If yes, please explain

Disclaimer:

"I understand that Advent Home Care Alliance will run a criminal background check to verify the responses given in the application process for the sole purpose of protecting staff, volunteers and others. By signing and dating below, you acknowledge your awareness of this background check and agree."

Signature*

Date*

Liability Disclaimer:

"I, and my heirs, in consideration of my participation with the Advent Home Alliance hereby release Advent Home Care Alliance, its officers, employees and agents, and any other people officially connected with this organization and/or event, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating with this organization/in this event. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely chose to participate. I understand that Advent Home Care Alliance does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur should the need arise as a result of my participation. I understand that I am acting as an independent contractor, and further, I understand that I am not entitled to workers compensation in the event of injury or death."

Certification of Application:

“I certify that all information submitted by me on this application is true and complete. I understand that if any false information, omissions or misrepresentations are discovered my application may be rejected and active volunteer status may be terminated.”

Signature 2*

Date*

Electronic Communications: Opt In or Out*

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Opt-out of text messages or electronic communications from AHCALL.

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Advent Home Care Alliance Volunteer Application

Do you have any special skills which you have or could bring to the events?

Please provide 3 references:

Disclaimer:

Liability Disclaimer:

Certification of Application:

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