Volunteer Application

Name *

Prefix First Name Last Name Suffix

E-mail *

Phone Number: *

- Area Code Phone Number

Address: *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Birth Date:

Month Day Year

School name (if student and under 18 yrs old)

Please let us know why you are interested in becoming a PTS volunteer. *

If applicable, what experiences have you had that may prepare you to work as a volunteer with veterans?

Please indicate your areas of interest:

Administrative Fundraising Special Events Linen Closet V.O.W. (Volunteers on Wheels)

Where did you hear about us?

Family Member Co-worker or Friend Facebook Volunteer Site Veteran Organization

Emergency Contact Information: *

First Name Last Name

Phone Number

- Area Code Phone Number

VOLUNTEER GUIDELINES

Minimum Age: 16 years and enrolled in high school courses.

Number of Hours Required: Volunteers must commit to at least a total of 20 hours and at a minimum of 4 hours of service per month. Please keep in mind the minimum of 4-hours per mnth may change depending upon the needs of PTS and your availability.

Interview(s): A screening interview must be scheduled with PTS prior to becoming a volunteer. Applicants are reviewed and considered based on assessed skills, interests, level of enthusiasm and motivation demonstrated towards commitment and the availability of volunteer positions.

Reference and Criminal Background: Upon successful completion of these checks, the applicant will receive a welcome letter.

Orientation and Training: Once the application, background check, interviews and placement form have been completed the prospective volunteer must become familiar with the Volunteers Services Manual.

Attendance: Volunteers are expected to meet their commitments of their scheduled service hours. PTS must be notified of any absences in advance or as soon as possible. PTS will monitor compliance very closely. After 3 consecutive unexcused absences without notification or extensive absenteeism, PTS reserves the right to terminate a volunteer.

Evaluation: All volunteers should demonstrate a good understanding of assigned tasks. A competency assessment by PTS will be given after 90 days of service and then on an annual basis of the volunteer’s start date anniversary. This assessment will be maintained in the Volunteer’s personal file.

Please read these clauses carefully and indicate your acceptance by checking the checkbox. *

Any information that a volunteer learns about Partners for Telehealth Solutions that is not otherwise publicly available constitutes confidential information. Volunteers may not disclose confidential information to anyone who is not employed by Partners forTelehealth Solutions who do not need to know such information to assist in rendering services. The disclosure, distribution, electronic transmission or copying of PTS’s confidential information is strictly prohibited. Any volunteer who discloses confidential PTS information will be subject to possible separation,even if he or she does not actually benefit from the disclosure of suchinformation. I understand the above policy and pledge not to disclose confidential information. I have read, understood, accepted and agree to abide by the CONFIDENTIALITY AGREEMENT for PTS. I understand that my personal and business affairs must be conducted in such a manner as to avoid any conflict of interest with my duties and responsibilities as a volunteer. A conflict of interest may exist when a volunteer, a volunteer’s family member,or any organization that a volunteer is affiliated with stands to gain, eitherdirectly or indirectly, from the volunteer’s involvement with PTS. I pledge to refrain from entering into any situation where a potential CONFLICT OF INTTEREST may exist. I have read, understood, accepted and agree to abide by the CONFLICT OF INTEREST policy for PTS. I voluntarily agree to accept and assume all responsibility and risk arising from my participation in this activity with PTS. My participation in this activity is purely voluntary. I also understand and acknowledge that no insurance benefits, medical or otherwise, will be provided to me by PTS during this activity or as a result of my participation in this activity. I agree that by volunteering for any activities which result in my driving a vehicle, I am certifying that I have a valid driver’s license and required insurance coverage. I VOLUNTARILY RELEASE PTS from any and all liability, claims, causes or rights of action that arise out of or are in any way connected with my participation in this activity, including, but not limited to any and all negligence, fault, or strictliability of PTS for any and all injury and damage to myself or to my property. I have read, understood, accepted and agree to abide by the WAIVER OF RESPONSBILITY policy of PTS. I understand that this is an application for and not a commitment or promise of volunteer opportunity. I hereby certify that my answers and assertions set forth in this application are true and complete tothe best of my knowledge, and I authorize the investigation of all statements contained within this volunteer application that may be necessary in arrivingat a decision for volunteer position. I understand that misrepresentations oromission may be cause for my immediate rejection as an applicant for a volunteerposition with Partners for Telehealth Solutions or my termination as a volunteer. I have read, understood, accepted and agree to abide by the DISCLOSURE AGREEMENT for PTS

Signature

Clear

Thank you for your interest in volunteering with Partners for Telehealth Solutions.

You will be contacted shortly.

Volunteer Application Form

Waivers and Disclosures