Crouse Community Center Volunteer Application

Name*

First Name

Last Name

Date of Application*

Address*

Address Line 1

City

State

ZIP Code

Phone*

Email*

Date of Birth*

Emergency Contact Name*

First Name

Last Name

Relationship*

Emergency Contact Phone*

Emergency Contact Address*

Address Line 1

City

State

ZIP Code

Present or Past Occupation*

Previous Work or Volunteer Experience*

Education or Special Training

Hobbies, Skills or Special Interests

Do you have a special area of interest for helping at Crouse Community Center? Are you interested in learning to lead your own activity programs?

Do you know a resident within Crouse Community Center?*

Yes No

Resident's Name

Hours Preferred: Weekdays

Morning Afternoon Evening

Hours Preferred: Weekends

Morning Afternoon Evening

Hours Preferred: Holidays

Morning Afternoon Evening

Personal Reference Name*

First Name

Last Name

Personal Reference Phone*

Personal Reference Address *

Address Line 1

City

State

ZIP Code

I understand the rules, policies and procedures of Crouse Community Center and will honor them.

Signature*

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Volunteer Orientation Check List
As a Volunteer I understand….

I must be complete medical clearance prior to beginning volunteering (Proof of MMR Vaccination, Flu Shot, Mantoux/PPD Test, Completion of Health Assessment with Employee Health).
A general background check will be performed with additional searches, should Crouse Community Center warrant it necessary.
That I will need a basic understanding of Alzheimer’s Dementia and have reviewed the materials provided by the Director of Education.
No Hands-On Giving of Direct Care to our residents; Meaning I will provide no toileting of residents, no transferring of residents, no feeding of residents.
No removal of residents outside the facility.
Resident confidentiality/HIPAA.
CCC Code Words.
Resident safety. Resident Rights & Abuse Reporting.
Hospice and End of Life Care as provided in this facility.
Crouse Community Center No Smoking policy, Cell Phone Policy, Social Media Policy.
I will sign in and out each day I volunteer. Sign in Log is locked at the main entrance.
My focus here to provide support for the activity department and assist in recreational activities or provide friendly visits with residents. If I have any questions or concerns I know I can talk to Kara Gemmell and the Activity Department Staff for Support.

Signature*

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Volunteer Code of Ethics

I will place the emotional and physical well-being of the residents ahead of my own.
I will treat each person as an individual, remembering the large range of emotional and physical abilities I may encounter as a recreation volunteer.
I will strive to provide a safe environment for everyone I may work with while serving as a volunteer.
I will lead by example by demonstrating integrity and good judgment to the residents of our programs.
I will learn the rules and regulations that pertain to my area, enforce them and teach them to others.
I will use appropriate behavior and language when working with the public.
I will remember that I am a Crouse Community Center Activity Volunteer and I will remember that my actions reflect on this department.

Signature *

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