Full Text
Greene County Senior Center Volunteer Application Personal Information Name Date of Birth Mailing Address City/State/Zip Email Address Social Security # Phone Day Evening Cell Emergency Contact Emergency Phone Day Evening Employer Phone # Do you have a valid driver’s license? Yes No If yes, provide number. Do you have auto insurance liability coverage? Yes No If yes, give name of carrier. Describe your general health for the past 12 months. Include any restrictions you wish us to be aware of. (No lifting etc.) Have you ever been convicted of a felony? Yes No If yes, please explain: provide a copy of your most recent background (yes answer does not automatically exclude you from becoming a Volunteer) Volunteer Experience Organization Location Dates Type Volunteer How did you hear about our Volunteer Program? Why do you want to volunteer? Any additional comments? References (two required) – Please do not list family members. Name Day Phone # Relationship to applicant Email Address Mailing Address City/State/Zip Name Day Phone # Relation to applicant Email Address Mailing Address City/State/Zip I authorize a representative of the Senior Center to check my references. Print Name Signature: Date Greene County Senior Center 1031 Silver Drive P.O. Box 759 Greensboro, GA 30642 [PHONE REDACTED] ---PAGE BREAK--- VOLUNTEER STATEMENT OF CONFIDENTIALITY 1. Confidential information pertaining to clients, volunteers and families should not be divulged to other family members or client’s/family friends. 2. Consultation with the Senior Center’s staff is strongly encouraged in attempting to provide the most appropriate assistance of our clients/families. 3. When in doubt about confidentiality issues, always contact the Senior Center Manager for clarification or assistance. Volunteer Statement of Confidentiality During the course of my volunteer work I may have access to confidential information about clients and families. I understand it is my responsibility to safeguard all information when in use, discussing it only with those employees and volunteers who have a legitimate need for this information. Signed: Date: