Volunteer Application Form
Please complete this application form if you are interested in becoming a NorthWest Senior & Disability Services volunteer. Once you complete the form, click the submit button at the bottom.
Please read before completing this application.
Due to the vulnerability of the clients we serve, all volunteers are required to undergo a criminal background check as part of the volunteer screening process. After enrollment as a volunteer, background checks are conducted annually. If you have not lived in Oregon for the past five years, you will also be required to have your fingerprints run through a national database. If you do not wish to participate in a background check, do not complete this applications.
Contact Information
First name:
*
Last name:
*
Street 1:
*
Street 2:
Street 3:
City:
*
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip:
*
Home phone:
Work phone:
Cell phone:
Email address:
Demographic Information
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.
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
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31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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2007
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2005
2004
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1999
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1980
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
*
(year optional)
What county do you live in?:
Choose
Clatsop
Marion
Polk
Tillamook
Yamhill
Education:
Choose
Associate degree
College degree
Doctoral degree
High school
Masters degree
Some college
Trade/Vocational school
Marital Status:
Choose
Declined to Answer
Domestic Partner
Married
Single
Widow/Widower
Gender:
Choose
Female
Male
Other
Race (check all that apply:
American Indian or Alaskan Native
Asian
Black or African American
Declined to Answer
Hispanic or Latino
Native Hawaiian or other Pacific Island
Other
Unknown
White
Volunteer Preferences
Please indicate the days and times you are usually available to volunteer.
# of clients desired:
List preferred cities or communities:
More preferred cities and communities:
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
Desired Service Type:
Advisory Council Member
Direct Service
Monitor
Office Aide
Team Leader
Languages Spoken:
American Sign Language
Arabic
Bosnian
Burmese
Cantonese
Chinese (Other)
English
Farsi
French
Hmong
Japanese
Khmer
Korean
Lao/Laotian
Mandarin
Mien
Other
Romanian
Russian
Somali
Spanish
Teochow
Vietnamese
What counties do you want to serve in?:
Clatsop
Marion
Polk
Tillamook
Yamhill
Please share why you are interested in becoming an Oregon Money Management volunteer.
Personal or professional references
Please provide the name, phone and or email for two non-family members and advise them to expect an inquiry.
1
2
First name:
First name:
Last name:
Last name:
City:
City:
Home phone:
Home phone:
Work phone:
Work phone:
Cell phone:
Cell phone:
Email address:
Email address:
Relationship:
Choose
Bill-pay client
Co-worker
Domestic partner
Family Member
Father
Friend
ICT client
Mother
Neighbor
Other
Pastor/Priest/Rabbi/Imam
Payee client
Social Worker
Spouse
Supervisor
Relationship:
Choose
Bill-pay client
Co-worker
Domestic partner
Family Member
Father
Friend
ICT client
Mother
Neighbor
Other
Pastor/Priest/Rabbi/Imam
Payee client
Social Worker
Spouse
Supervisor
Emergency contact
Who should we contact in the event that you become involved in an emergency situation?
First name:
*
Last name:
City:
Home phone:
Work phone:
Cell phone:
Email address:
Relationship:
Choose
Bill-pay client
Co-worker
Domestic partner
Family Member
Father
Friend
ICT client
Mother
Neighbor
Other
Pastor/Priest/Rabbi/Imam
Payee client
Social Worker
Spouse
Supervisor
Volunteer source and experience
Please share from where you learned about the Money Management Program and about any experience that you have as a volunteer or with money management.
Volunteer Source:
Choose
AARP
Craigslist
Hands On
Internet
Newspaper
Other
RSVP
Volunteer Match
Word of Mouth
Please share your experience as a volunteer or your experience with money management.
Confidentiality Agreement
Confidentiality is the preservation of privileged information concerning a client, which is disclosed in a professional working relationship. Part of what volunteers learn is necessary to provide services to the client; other information is shared within the development of a helping, trusting relationship. Therefore, most information gained about individual clients throughout an assignment is confidential in terms of the law, and disclosure would make you legally liable. Disclosure could also damage our relationship with the client and make it difficult to help the person.
All records dealing with specific clients must be treated as confidential. General information, policy statements or statistical material not identified with any family is not classified as confidential.
Before you begin your assignment as a volunteer, you should be aware of the laws and penalties of breaching confidentiality. Violation of the Oregon Revised Statues regarding confidentiality of records is punishable upon conviction by fine of not more than $1,000,00, or by imprisonment in the county jail for not more than 60 days, or both. It also may be reason for dismissal in your position.
Confidentiality Agreement:
Hold Harmless Agreemement
I release, indemnify and hold harmless NorthWest Senior & Disability Services, its officers, agents and employees from any and all claims, actions and demands that may arise from my actions as a volunteer. I also understand that my volunteer involvement can be terminated at the discretion of the agency at any time. I understand that if I use my personal vehicle to and from y volunteer position, that I am agreeing to keep in effect automobile liability insurance equal to or greater than the minimum required by the state of Oregon.
By checking the box below I acknowledge that I understand and agree to this policy.
Hold Harmless Agreement:
Password
With your email address and password you will be able to log into our on-line volunteer center to update your contact information, change your preferences, update your client information, and complete your monthly volunteer report. The link to log in is located on the Money Management Page. Passwords are not case sensitive and may be letters or numbers or a combination of both. Be sure to record your chosen password in a secure location.
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:
I Agree
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