HILLVIEW HEALTH CARE CENTER

VOLUNTEER APPLICATION
 

I.   First Name:       
     Last Name:    Date: 
      
     Address:   
     Home Phone:     Best Time To Call:   

     E-mail Address:

 
     Emergency Contact (name and phone number):   
     Relationship:  
   
     References: (only one may be a relative; list names and phone number with area code)  
     1.     2.  
             
   
      Background Check:  (Every volunteer is subject to a background check as Hillview does not accept volunteers with any          
      cases of theft or abuse.)   
      First Name:   Middle Name:  Last Name:   
      Birthdate: (00/00/0000 format) 
   
        
II.  This section for college students only.  
   
School:      Major:   
Class requiring volunteer hours:     Hours required for classwork:  
   
III. Frequency with which you wish to volunteer. (check preference)  
   
  Weekly (1,2, or 3 days)                   Every Other Week   Weekends Only  
       
  Monthly   Other:  
       
IV. Time Preference/Skills/Abilities. (check preference)  
   
Mornings:  Afternoons: Evenings:  
9:00 a.m. - 1:00 a.m. 1:00 p.m. - 4:00 p.m. 6:00 p.m. - 8:30 p.m.  
   
ALL VOLUNTEERS MUST GO THROUGH A 1-HOUR ORIENTATION SESSION.  
   
Days of the Week Preferred:  
   
Any skills, hobbies, or previous experiences you would like to share:  
 
   
Any physical limitations:  Yes   No  
   
If yes, please explain:  
 
   
V.  Possible Areas of Work Preference (Please mark your preferences.)  
   
Help with Parties  
Provide Instrumental Talent  
Provide Vocal Talent  
Help In Making and Putting Up Decorations  
Taking Residents for Walks/Rides/Outings  
                   With Staff       Without Staff  
Transporting Residents To Activities  
Helping To Prepare for Special Events (Christmas, Halloween, Valentines, etc)  
Book Cart (Distributing Books/Magazines/Puzzles)  
Play Music/Read/Simple Games for Room Bound Residents  
Help With Programs for Low Functioning Residents (Creative Stimulation, Lounge Program)  
Work with the Resident Rooms  
Teach a Special Talent (Drawing, Knitting, etc)  
Assist During Craft Projects/Woodworking  
Friendly Visits to Residents Rooms  
Letter Writing  
Outdoor Gardening  
Assist Exercise Group  
Ladies Fingernail Painting  
Bulletin Board Ideas  
 
By submitting this form, I understand that it is my responsibility to keep confidential any information I learn about the residents and/or their family, and that violating confidentiality is cause for immediate dismissal.

Rev. 10/01