Centrica Care Navigators Volunteer Application

Centrica Care Navigators Volunteer Application
CONTACT INFORMATION
Full Name*

First Name & Middle Initial Last Name
E-mail*
Address*

Street Address

Apartment no. or P.O. Box

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Best time to contact (Morning, Afternoon, Night, or Any Time)*
Are you 18 years of age or older?*

YesNo

Do you have any special skills (Hair Stylist, Barber, Sing, etc.) or interests? Example:
Do you have a valid driver's license?*

YesNo
Are you a veteran?*

YesNoI decline to identify
If you served in the military, please indicate which branch of service.
Emergency Contact
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*

CRIMINAL BACKGROUND CHECK AND REFERENCES
Centrica Care Navigators regrets that an individual who has been convicted of a felony, or who has charges pending, is not eligible to volunteer. Misdemeanor convictions will be assessed according to Centrica Care Navigators Criminal Background Check Policy (available upon request). We
will be providing a Criminal Background Check form to you at or prior to your interview with us. Your answers are confidential.
Have you ever filled out a Volunteer Application with Centrica Care Navigators?*

YesNo
If Yes, When?

Statement of Consent

I acknowledge that the information I have supplied is correct to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from the volunteer program.

I understand that consideration for volunteer placement is contingent upon the results of reference, screening for TB and background checks including a criminal check. I therefore authorize this Agency to investigate all statements made on my application and to discuss the results of the investigation with those responsible for volunteer selection and placement. I further authorize the Agency to contact my current and former employers and any listed reference or other persons who can verify information and I give my consent for my employers and other contact persons to respond to questions pertaining to information on this application.
Date*

MonthDayYear
Date
Applicant Signature*

Clear
Thank you for your interest in Centrica Care Navigators. All information you provide will be kept confidential. We consider applicants for all positions without regard to age, color, creed, disability, handicap, height, weight, marital status, national origin, race, religion, sex, sexual preference, or liability for service in the armed forces. Our concern for the quality of our Volunteer Services program and the safety of our patients requires Centrica Care Navigators to select only the applicants who best meet our current needs. Therefore, submitting a volunteer application does not mean you will be selected as a volunteer. Upon review of your application, our Volunteer Program Manager or one of our Volunteer Coordinators will contact you.
Should be Empty:

	Interested	Possibly Interested	Not Interested
Hospice Clients: Work directly with clients receiving hospice services (Companionship, Respite, Story Catching/Editing, Light Housekeeping, etc.)
Administrative/Office Support Roles
Journeys:Grief Support Program for children and families
Rose Arbor Place: Greeting, Laundry, Meals, etc.
Pet Therapy Services with my dog
I have not decided yet.

Centrica Care Navigators Volunteer Application

CONTACT INFORMATION

Emergency Contact

VOLUNTEER INTERESTS AND AVAILABILITY

CRIMINAL BACKGROUND CHECK AND REFERENCES