Waveny Volunteer Application
Please complete this form if you are interested in becoming a Waveny LifeCare volunteer. After completing the form, click the submit button and you will be contacted by our Volunteer coordinator to arrange an interview and training/orientation.
Volunteer opportunities are available at our Independent, Assisted Living and Skilled Nursing residences in New Canaan, at our Home Health Care and Hospice Services office at 22 Danbury Rd, Wilton and at the New Canaan Thrift Shop, 2 Locust Ave, New Canaan.
** Adults (18+) will need to complete PPD screening for TB before volunteering. This will be provided by Waveny at no cost **
Contact Information:
First name:
*
Last name:
*
Title:
Choose
Dr.
Miss
Mr.
Mrs
Mrs.
Ms
Ms.
Street 1:
*
Street 2:
City:
*
State:
Choose
CT
NJ
NY
*
Zip:
*
Home phone:
OK to call me here
Cell phone:
OK to call me here
Email address:
*
Date of birth:
Month
Jan
Feb
Mar
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Jul
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Day
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2021
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*
Gender:
Choose
F
M
** Junior Application ** (18 & under):
Junior Volunteers need to be entering 9th Grade in the Fall of 2021 to participate in our Summer High School Volunteer Program. Younger volunteers may schedule activities accompanied by a parent.
School:
Grade:
Parent/Guardian Name(s):
Education or Special Training:
Any specific education or special training that would relate to Waveny or volunteering.
Previous Volunteer Experience:
List any previous volunteer experience.
Community Affiliations:
Emergency Contact:
First name:
*
Last name:
*
Street 1:
*
Street 2:
City:
*
State:
Choose
CT
NJ
NY
*
Zip:
*
Home/Cell phone:
*
Work phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Employer:
Please list your current or most recent employer, if applicable.
Employer name:
First name:
Last name:
Street 1:
Street 2:
City:
State:
Choose
CT
NJ
NY
Zip:
Work phone:
References:
Reference from employer or other Waveny volunteer. Hospice Volunteers please complete two references.
1
2
First name:
First name:
Last name:
Last name:
Home/Cell phone:
Home/Cell phone:
Volunteer Agreement
I understand and agree that submitting this application does not automatically register me as a Waveny LifeCare Network volunteer. There may be certain qualifications I must meet, including passing a criminal background & sex offender check (18+), completing a PPD screening for TB (18+) and the acceptance of established volunteer policies and procedures before I may begin volunteering.
By submitting this form, I agree to the terms above and I attest that the information I have provided on the form is true and accurate.
I Agree
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