Individual Volunteer Application Form

Welcome! Please complete this application form if you are interested in becoming a Danbury Senior Living Huber Heights volunteer. Once you complete the form, click the Continue button at the bottom.

If you are the leader of a group who will be coming in, please see our Group Application.

**PLEASE NOTE: The "What should residents call you?" question is what we will put on your nametag. Whether you'd like to be known by your first name (Maria), a less formal title (Sister Suzanne or Pastor Kyle), or a more formal title (Rabbi Smith), please specify that in this field. ***

Contact Information

First name:

Last name:

Middle name:

Title:

What should residents call you?:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Date of birth:

* (year optional)

Skills & Experience

In which of these areas do you feel you have moderate to excellent skill? Check all that apply.

Volunteer Log/ Service Program

The following information will help us get to know you, as well as help us with our volunteer award programs.

The two numbered sections are to list any friends/ relatives you may have at Danbury Senior Living. This is so that we may thank them for referring you to our volunteer program!

T-Shirt size:

School:

High school:

College:

Comments:

Availability

Please indicate the days and times you are usually available to volunteer. (This does not commit you to anything!)

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

Comments:

There are no scheduling options available

Assignment Preference

The following volunteer assignments may currently be available. You may click the assignment names to learn more about that assignment. Use this list to rank your top three assignment choices.

Emergency Contact

In the unlikely event of an emergency, who should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Relationship:

Employer or Personal References

Please list your current or most recent employer, if applicable, along with one personal reference. If not employed, please provide two personal references.

1

2

Employer name:

First name:

Last name:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Email address:

Relationship:

EMail

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

Volunteer Information Center

We provide an online "Volunteer Information Center" where volunteers may check their schedules, update their information, and receive messages. Please select the password you would like to use to access the online Volunteer Information Center.

Please enter a password that:

Is between 8 and 30 characters long
Contains both letters and numbers.
Contains a combination of both uppercase and lower case letters.

Password:

Confirm password:

Allow other volunteers to see when I am scheduled

Demographics

You may *optionally* provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Gender:

Education:

**OPTIONAL** IF you would like to share your religion here, please do so. This would only be utilized if you have volunteered to visit 1-1 with residents, be a Prayer Partner, etc. so that we may make a suitable match.

Referrals

Please indicate any friends/ relatives you have at Danbury Senior Living Huber Heights.

1

2

First name:

Last name:

Relationship:

If you don't yet know anyone at Danbury, how did you hear about our volunteer opportunities?

I Agree

APPLICATION: I understand and agree that submitting this application form does not automatically register me as a Danbury Senior Living Huber Heights volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

COMPENSATION: Volunteering is not a paid position. I understand that as a volunteer I am not entitled to any type of compensation (financial or otherwise).

CONFIDENTIALITY: I understand that as a volunteer I may learn confidential information in the course of my duties, and I agree not to disclose information regarding residents or their health status outside of Danbury.

TB TEST: I understand that the state of Ohio requires health care volunteers to have a TB test if they are volunteering 10 or more hours in a facility in a calendar month. I agree to either have this test performed by my doctor and provide a copy to Danbury, or, to keep my volunteer hours under the 10-hour limit.

LEGAL: By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree

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