Application to Volunteer (Homestead)

Application to Volunteer

The Homestead Assisted Living
Applicant Information
Today's Date:*

MonthDayYear
Volunteer's Name*

First NameLast Name
Cell Phone Number*
E-mail*
Please enter your most often used email, as it will initially be the primary source of communication with you.
How frequently are you wanting to volunteer at The Homestead?*

Just once (such as a church group, college class,Once a weekOnce a MonthMultiple times per weekOther
Do you want to be on the weekly Volunteer Email List? This is how we notify Volunteers of service opportunities for the week.*

YESNO
Below is an area to explain your ideas, interests, and why you want to volunteer at The Homestead: (Optional)
Questions
Have you been convicted of a felony or misdemeanor?*

YesNo
How did you hear about volunteering at The Homestead?*

FacebookReferralBYU-ICraigslistOther
Thanks for the desire to volunteer at The Homestead Assisted Living!

Federal HIPAA regulations state that the resident guests here at The Homestead have personal information that is confidential.

Some items of Protected Health Information (PHI) include:
- Information that is related to a resident's past, present or future health or condition.
- Any information that can be used to specifically identify the resident.
  - Name
  - Room number
  - Social Security Number
  - Photographs
  - Date of Birth
  - Contact information (phone number, email... etc).
Volunteers may have access to confidential information, both written and oral, during the course of their volunteer time at The Homestead Assisted Living. It is imperative that this confidential information is not disclosed to any unauthorized individual to maintain the integrity of the resident’s information.

Volunteers must agree to maintain confidentiality of all information obtained during the course of their time volunteering, including but not limited to: financial, technical or proprietary information of the organization and personal and sensitive information regarding patients, employees and vendors.

Inappropriate disclosure and/or release of patient information is grounds for termination of volunteer status and other disciplinary action from legal authorities.
In order to ensure that both you as a volunteer, and the facility will mutually benefit from your volunteer experience, some guidelines have been established for you. Please read, understand and sign below showing you will implement the following:

Volunteers must follow Federal HIPAA rules and guidelines regarding The Homestead, it's residents and staff members.All volunteers working directly with residents must be trained by an appropriate staff member prior to the volunteer working with any resident, including walking, using wheelchairs...etc.Volunteers will always be within visual range under a Homestead staff member's supervision while working with residents.Volunteers are not permitted to bathe, toilet or dress a resident at any time.Volunteers may assist with feeding, visiting, reading, planned daily activities etc... when they have received proper training from a Homestead staff member.A volunteer that has discovered a resident incident must alert a Homestead staff member immediately and never assess, diagnose or assist the resident during an incident.All facility policies, rules and regulations apply to all volunteers.Volunteers should provide their own meals if present within the facility during meal time.Volunteers are under the supervision of the facilities' management staff.Volunteers must be professional at all times and adhere to confidentiality policies.Volunteers are not permitted to enter a resident's room unless accompanied by the facility activities director.The Homestead Assisted Living reserves the right to refuse volunteer service at any time for any reason.Volunteers giving time and service at The Homestead do not receive monetary compensation for services provided to the residents.
Signing below signifies that you have read the above rules about volunteering at The Homestead, and that you intend to fully adhere to and follow them.
Please use your mouse or finger to sign on the line:*

Clear
Thank you for the interest in volunteering at The Homestead!

When you're completely finished, click Submit below.

We look forward to serving our beloved residents alongside you, and we hope to see you soon!
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