Senior Living Group Volunteering Application

Group Volunteer

* Required

Name of Group*

Contact First Name:*

Contact Middle Initial:

Contact Last Name:*

Address:*

City:*

State:*

Zip:*

Preferred Phone:*

Alternate Phone:

Email address of contact at organization:

Volunteer Experience:

Employment Experience:

Special Skills or Training:

Select community you wish to serve (check all that apply):
 Beatrice Place Brentland Woods Center for Rehabilitation The Episcopal Church Home Pinehurst River Edge Manor Rockwood Center Seabury Woods Valley Manor Multiple Sites No Preference

Availability & Frequency:
 One Time Weekly Monthly

Volunteer Job Preferred:

Fill in times below:

Hours
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning:  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Afternoon:  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Evening:  Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Emergency Contact Information

First Name:*

Middle Initial:

Last Name:*

Address:*

City:*

State:*

Zip:*

Preferred Phone:*

Alternate Phone:

Relationship:

Professional References

(Two individuals who can speak to your character, reputation, and work experience).

First Name:*

Middle Initial:

Last Name:*

Address:

City:

State:

Zip:

Preferred Phone:*

Alternate Phone:

Reference #2

First Name:*

Middle Initial:

Last Name:*

Address:

City:

State:

Zip:

Preferred Phone:*

Alternate Phone:

Optional

Faith Community:

Phone:

Clergy Name:

Email:

* 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.
* 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 grounds for immediate dismissal.

Please sign this application by typing your name below.

Signature:*

Date:*

Referred By: