The Maplewood - Volunteering

Full Name:

Address 1:

Address 2:

City:

State/Province:

Zip/Postal:

Birthdate:

When can you start?:

Email Address:

Home Phone Number:

Cell Phone Number:

What time of day works best for you?:

Mornings
Afternoons
Evenings
Other

Emergency Contact Name:

Emergency Contact Address 1:

Address 2:

City:

State/Province:

Zip/Postal:

Relationship:

Emergency Contact Phone Number:

Do you have any special talents? If so, please list them:

Do you have any physical limitations?:

YesNo

Are you willing to get a flu shot during flu season?:

YesNo

Are you physically capable of pushing a wheelchair?:

YesNo

(There are opportunities to volunteer that do not require pushing wheelchairs)

Have you ever worked with the elderly before?:

YesNo

Have you ever been convicted of a crime, other than minor traffic violations? :

YesNo

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION FORM:

I understand that in conjunction with this application, Maplewood will be performing a background check and a check of the state nurse's aide directory for all prospective volunteers. I further understand that smoking is strictly prohibited on Maplewood grounds and that it is my duty to abide by this policy and enforce it when necessary. I verify and affirm that all information provided in this application is true. I understand that any misrepresentation or omission of facts will be suffcient cause for immediate dismissal from volunteering at Maplewood Nursing Home. If you understand please sign your name below.

Signature:

Volunteering

MAKING A DIFFERENCE

Volunteer Today

APPLY TO BECOME A MAPLEWOOD VOLUNTEER