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Volunteer Application

Sunrise: ___________________________________________ Date: ________/________/________


Name: ___________________________________________________________________________
Last
First
Middle Initial
Address: _________________________________________________________________________
Street
_________________________________________________________________________
City
State
Zip Code
Telephone Number: (Days): ______________________
(Evenings): _____________________
Cellular/Alternate Number: __________________ E-Mail: __________________________________

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:

time: _________ to _________


time: _________ to _________
time: _________ to _________
time: _________ to _________

Friday:
time: _________ to _________
Saturday: time: _________ to _________
Sunday: time: _________ to _________

PERSONAL REFERENCES (Personal references must be 21 years of age or above.)


1. Name: ______________________________________________ Relationship: _________________
Last

First

Middle Initial

Address: _____________________________________________ Telephone: ___________________

2.

Name: ______________________________________________ Relationship: _________________


Last
First
Middle Initial
Address: _____________________________________________ Telephone: ___________________

VOLUNTEER TERMS OF AGREEMENT


I.

Gift Acceptance Statement


It has been explained to me and I understand that as a volunteer at Sunrise I am not allowed to
accept money including gifts or tips from any resident. We serve all residents equally and must
graciously decline all gifts or tips. If the resident persists, I will refer the concern to the activities &
volunteer coordinator for resolution.

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.

Volunteer Signature: _______________________________________ Date: __________________

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