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GENERAL INFORMATION
Emergency Contact: _________________________________________________________________
Name
Relationship
Telephone #
Are you applying as an: Individual Adult Individual (Youth) Organization
Organization Name: __________________________________________________________________
Have you ever applied for work at Sunrise? Yes No
If yes, when and at which community? ___________________________________________________
___________________________________________________________________________________
Have you ever been convicted of a crime? Yes No
If yes, please provide date(s) and identify offense(s): _______________________________________
___________________________________________________________________________________
Current Employment/School: __________________________________________________________
VOLUNTEER INFORMATION
How did you learn about volunteer opportunities at Sunrise? _________________________________
___________________________________________________________________________________
Why do you wish to volunteer at Sunrise? ________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
What prior volunteer experience do you have? ____________________________________________
___________________________________________________________________________________
Do you have any prior experience working with individuals who have Alzheimer's disease or related
dementia? Yes No
If yes, with whom and where? _________________________________________________________
Do you have any interest in volunteering as a driver? Yes No
If yes, provide your Social Security #: _____ - _____ - _____ and Date of Birth: ___ / ___ / ____
Do you prefer: Individual Activities Group Activities
What skills, interests, or hobbies would you like to share with others? __________________________
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
Do you speak any other languages? Yes No
If so, what languages? ____________________________________________________________
REV. 10/24/08
QPD-2158_VA
AVAILABILITY
Specify days and hours you are available to volunteer (Please indicate A.M. or P.M.):
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
time: _________ to _________
Saturday: time: _________ to _________
Sunday: time: _________ to _________
First
Middle Initial
2.
II.
Confidentiality Statement
All Residents have Rights and Responsibilities including the right to privacy. As a volunteer, you
may learn confidential information about the residents. You must uphold each Resident's Right to
Privacy by keeping these matters confidential. The only exception to this is in emergency situations.
Passing along accurate and complete medical information to the physician, emergency room,
rescue squad, hospital staff and nurses, etc. in an emergency is a part of our responsibility and is
not a breach of confidentiality: I agree to comply with these confidentiality obligations.
III.
Volunteer Authorizations
I authorize Sunrise to obtain information from schools, listed references, or other individuals and
institutions it contacts regarding the information I have provided on this application. I understand
that I will be subject to a criminal background check, TB Test (Tuberculosis / Mantoux), Drug/Alcohol
screening & Motor Vehicle Records check (when applicable) as a condition of performing volunteer
activities. I understand that I am obligated to report any information which may be helpful in meeting
the needs of the residents of the Sunrise community in which I volunteer. I also understand that my
volunteer orientation requirements differ depending upon my assignment by the activities &
volunteer coordinator. I agree to follow the established guidelines outlined here and in the Volunteer
Orientation Guide.
Sunrise Senior Living appreciates your interest in volunteering and reserves the right to
make decisions based on the Residents' needs. Thank you.
REV. 10/24/08
QPD-2158_VA