Volunteer Application Form

Episcopal Church Home • Brentland Woods
River Edge Manor • Seabury Woods

Name:

Address:

City:

Zip:

Home Phone:

Business Phone:

Birth Month/Day:

Email Address:

Volunteer Experience:

Employment Experience:

Special Skills or Training:

Volunteer Job Preferred (See Opportunities Sheet):

Availability & Frequency:

Weekly

Monthly

On Call

Fill In Times Below:

Hours	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Afternoon
Evening

Are you away for any extended time during the year?

If so, When?

Emergency Contact #1 Information
Name:		Home Phone:
Address:		Business Phone:
Relationships:

References (Two people, not relatives, we can contact that can vouch for your character, reputation, and work record).
Name:		Home Phone:
Address:		Business Phone:


Name:		Home Phone:
Address:		Business Phone:

OPTIONAL Church:

Clergy:

Have you ever been convicted of a crime (other than traffic violation)?:

If so, please explain:

Do you have a final finding of patient or resident abuse?

Were you ever removed from any type of employment?

Note: Prior criminal conviction is not necessarily a bar to volunteering.

I authorize Episcopal SeniorLife Communities to verify the accuracy of information provided on this application and to obtain reference information. I hereby release Episcopal SeniorLife Communities, and party supplying references, from any liability for a placement decision based on such information.

Please sign this application by typing your name below.

Signature:

Date:

Referred By:

I understand that, if I am accepted as a volunteer with Episcopal SeniorLife Communities, I will be expected to observe confidentiality with respect to all information regarding my interactions with residents, staff, and family members at ESLC and any knowledge of the contents of confidential records. Failure to adhere to this agreement is ground for immediate dismissal.

Click here to submit this application.