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Volunteer Application

Brethren Care Village Volunteer Application

First Name:*

Last Name:*

Address:*

City:*

State:*

Zip Code:*

Birthdate (Month/Day ONLY):*

Are you over 18?*

Yes	No

Home Phone:*

Cell Phone:*

E-mail:*

Have you taken a Tuberculosis (TB) skin test within the calendar year?*

Yes	No

Person to Notify in Case of Emergency

Name:*

Phone:*

Relationship:*

Limitations to your health:

Previous Volunteer Experience (List Organizations):

Availability (check all that apply):

Days:

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

How Often:

Daily
Weekly
Bi-weekly
Monthly

Times:

AM	PM

Activities of Interest (check all that apply):

Bingo
Bowling
Cards
Crafts
Exercise
Games
Gardening
Music
One-on-One Visits
Quilting
Reading
Scrapbooking
Special Events
Walking
Other (please specify)

I want to volunteer because:*

How did you find out about our volunteer program?

Expectations
Volunteers are expected to comply with all laws and regulations that apply to Brethren Care Village. In addition, volunteers should maintain the highest ethical standards of conduct in all activities and services as an extension of the Mission, Values, and Policies of Brethren Care Village. Any political, religious, or personal beliefs that are not consistent with Brethren care Village's Mission, Values, and Policies should not be shared on our Campus, in our buildings, with staff, residents, or family members. Volunteers are to treat residents with care and respect, adhering to privacy, confidentiality, and conflict of interest rules.

Opportunities to volunteer are provided without regard to religion, creed, race, nation origin, sex, or age. The volunteer services department is not obligated to provide placement, nor am I obligated to accept an offer to volunteer.

Confidentiality
I understand that all information pertaining to residents and families at Brethren Care Village is confidential. By signing this document, I promise to adhere to Brethren Care Village's policy in keeping any resident and family information I may acquire while volunteering completely private and confidential. I also agree not to take personal pictures or recordings of residents, family member, or staff. I understand that I am not allowed, under any circumstances, to transport a resident from Brethren Care Village. I also understand I am not allowed to bring guns, alcohol, or tobacco to Brethren Care Village. I understand that I will be required to complete Training related to resident privacy, administrative business functions and security of health information during orientation.

Substance Abuse
By signing this document, I am verifying that I am a drug-free individual, and do not abuse alcohol, controlled substances, prescription, or over the counter medications. I understand that Brethren Care Village reserves the right to request a drug and/or alcohol test if there is suspicion I am under the influence of a substance while volunteering for Brethren Care Village.

Volunteer's Initials:*

Our Services

Watch an interview about the new Wasen Rehabilitation Center!