Individual Volunteer Application Form

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

Name:

Address:

City:

Zip:

Primary Phone:

Secondary Phone:

Birth Month/Day:

Email Address:

Volunteer Experience:

Employment Experience:

Special Skills or Training:

Select community you wish to serve (check all that apply):

The Episcopal Church Home Brentland Woods River Edge Manor
Seabury Woods Multiple Sites Unknown

Volunteer Job Preferred (See Opportunities Sheet):

Availability & Frequency:

Weekly

Monthly

On Call

Fill In Times Below:

Hours	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning
Afternoon
Evening

Are you away for any extended time during the year?

If so, When?

Emergency Contact Information
Name:		Home Phone:
Address:		Business Phone:
Relationship:

Professional References (Two individuals who can speak to your character, reputation, and work experience).
Name:		Primary Phone:
Address:		Secondary Phone:


Name:		Primary Phone:
Address:		Secondary Phone:

OPTIONAL
Faith Community:

Clergy Name:

Phone:

Email:

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.