Guidelines | Volunteer Applications | Pet Pals
Adults and Retiree Application
Last Name:
First Name:
Middle:
Address:
City:
State: Choose State... AK AL AR AZ CA CO CT DE FL GA HA IA ID IL IN KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TE TX UT VA VE WA WI WV WY
Zip:
HomePhone:
Current Occupation or Previous Employment
Are you retired? Yes No
Are you still attending school? Yes No
Volunteer Experience:
Special Training:
Languages:
Speak Fluently:
Read:
Write:
Have you been convicted of a crime other than a minor traffic violation? Yes No
Days Available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
I am most interested in: Resident Contact Clerical
Who referred you to us? (relative/friend/HHAR employee)
Contact in Emergency:
Relationship:
Phone:
Hobbies:
Please list two (2) personal/business references:
Name:
CONFIDENTIALITY PLEDGE
In complying with the policies/procedures and professional standards of the Home, I will keep any personal or medical information about the residents strictly confidential, not to be shared or discussed with any unauthorized person(s), either inside or outside of the faculty. I have a full understanding of this statement of confidentiality.
Print Name:
Date:
