Alzheimer’s Activity Center
2380 Enborg Lane
San Jose, CA 95128
408-279-7515
Service Learning
Volunteer/On -Site Student Application
Date:______
Name______Phone______
Email______
Address______Street City Zip
Occupation/School______
Do you have any physical limitations that may restrict your participation, or may
need any accommodations to perform the functions needed. Please state:
______
Special skills or hobbies______
Release Form
Respite and Research for Alzheimer’s Disease will provide training for volunteers/on-site students. Such Volunteers/on-site students may then assist the Alzheimer’s Activity Center in programs and management of clients under staff supervision. The undersigned releases and holds harmless RRAD and the Alzheimer’s Activity Center, its employees, and agents from any and all injuries, claims, demands, costs, damages and liability resulting directly or indirectly from volunteering at the Alzheimer’s Activity Center.
Read, understood and agreed to by:
Signed:______Date:______
Waiver Form
Worker’s Compensation
I, ______, understand that I am not considered an employee of the Alzheimer’s Activity Center while performing volunteer work for the organization. I further understand that as a volunteer/on-site student, I am not covered by Worker’s Compensation Insurance (medical coverage or loss of wages) for any injury that may occur while I am acting as a volunteer.
Read, understood and agreed to by:
Signed:______
Date:______
If the volunteer is under the age of 18 years old, this form must also be signed
and dated by his or her parent or responsible party.
Signed:______
Date:______
Emergency Medical Care Authorization
In case of a medical emergency while I, ______am
working at the Alzheimer’s Activity Center, I hereby authorize the following.
1. Arrange for emergency medical treatment.
______
Hospital and Phone Number
Date of last TB test______
2. Contact attending physician
Name______
Street______
City, State, Zip______
Phone______
3. Contact family or responsible party.
______
Name Phone
Medical Number______
Dentist______Phone______
Signature______Date______
In case of emergency medical treatment, the following will happen:
1. Dial 911 - for emergency transportation to the hospital and further evaluation.
2. Contact responsible party listed above.
PROCEDURES
1. Record your service hours for each day of attendance. There is a particular
volunteer sign - in book according to your affiliation.
2. Please notify the AAC, if you are going to be absent or arriving late. The
Center’s telephone number is 408-279-7515.
3. Please use a Center’s nametag (please legibly print your first name only)
HELPFUL SUGGESTIONS
1. Familiarize yourself with the Alzheimer’s Activity Center and the services it
provides.
2. Learn names of the clients with whom you will be working with.
3. Observations about clients, which are pertinent, should be reported to the
Activity Director or Lead Staff so they can be addressed and documented.
4. If you experience any difficulty with a client, staff member, or procedure
please notify the Activity Director or Director of Education.
5. You can improve community awareness for the needs of the frail elderly by
relating your experiences to others in a respectful manner.
6. Please feel free to inquire about recommended reading on Alzheimer’s
Disease.
POLICY
1. Everyone has the right to privacy. You are asked not to discuss the clients by
name outside of the Center.
2. Never discuss a client in his or her presence.