337StephensAve
MissoulaMT59801
406.728.7682
volunteer@missoulaagingservices.org
NONPAIDSTAFFAPPLICATION
DateofApplication:
LastName:FirstName:Middle:
(PleasePrint)
StreetAddress:(required)
Street Apt# City State ZipCodeMailing Address: (Ifdifferentfrom streetaddress) Street Apt# City State Zip Code
TelephoneNumbers: Home:Cell:
E-Mail Address:@
Dateof Birth://Driver’sLicenseNumber:
MM/DD/YYYY
AutoInsuranceCompany:
Pleasebrieflylistthefollowinginthespacesprovided:
Employment History:VolunteerExperience:
HowwereyoureferredtoMissoulaAgingServicesforvolunteeropportunities?
WordofMouthTelephoneBookNewspaperRadio/TV
Poster/FlyerDropinVisitWebsiteOther
Please list two references (name, mailing address and phone) that are not related to you, but are familiar with your work and/or relevant skills,either paid or non –paid, whom we may contact. (As a courtesy, be sure to inform your references that we will be contacting them).
1.
2.
Haveyoueverbeenconvictedofafelony?YesNo(Convictionwillnotnecessarilydisqualifyanapplicant)
EmergencyContact:Relationship:
Address:Phone:
IncludeCity/ST/Zip
Iamavailabletovolunteer:Mon Tue WedThuFriMorningAfternoon
ContinuedonReverse
Iwouldlike tovolunteerforthisspecificprogram:
CertificationofInformationandConfidentialityAgreement
Icertifythattheinformationprovidedonthisapplicationistruetothebestofmyknowledge.Iunderstandthatanymisinformationormaterialomissioncouldresultinunfavorableconsiderationorimmediatedismissal.Iallowreleaseofthisinformationforverificationandevaluationpurposes,whichmayincludeabackgroundcheckandreleaseofdrivingrecord.Iauthorizecontactofmypersonalreferencesforverificationandevaluationpurposes.IfIamusingmyownvehicle,Iagree toprovideinsuranceasperMontanaStatelaw.Iunderstandvolunteers’photographsmaybeusedforpublicityfornewspurposes.IagreenottoholdMissoulaAgingServices,oranyofitsprograms,liableforanyincidentoraccidentthatmayoccurwhileperformingavolunteerservice.
MissoulaAgingServicesvaluestheprotectionofconfidentialinformationconcerningclients,caregivers,volunteersandco-workers.Itistheobligationofeveryemployee,student/workstudy,andvolunteerstaffmembertomaintainthisconfidentiality.
WhenworkingwithMAS,non-paidstaffwillnotdiscussorotherwisedivulgeanyinformationconcerninganyclient,customerorfellowstaffmemberofMissoulaAgingServicesexceptonaneedtoknowbasisforthebenefitoftheclient,customerorfellowstaffmember.
Whenworkingwithotherorganizations,non-paidstaffwillnotprovideproprietaryinformationtoanyoutsideorganizationorindividual,unlessauthorizedbymanagement,client,customerorstaffmemberornecessaryintheperformanceoftheirduties.Thisincludescomputergeneratedformsoranyothergeneratedinformationofanysort.
Carewillbetakenatalltimestoseethatcasefoldersandotherconfidentialinformationaresecureandnotaccessibletoothers.
Ihavereadandagreetoadheretotheconditionsofthisconfidentialityagreement.Ialsoacknowledgethatanybreachofconfidentialitymayresultindisciplinaryactionuptoandincludingtermination.
Signature:Date:
ThisinformationisONLYNEEDEDfromvolunteersintheFosterGrandparent, SeniorCompanionandRSVPMissoulaSeniorCorpsPrograms.Placementwiththeseprogramsincludesfreeexcessliabilityinsurancecoverage.
InsuranceBeneficiary:
Address:
City:State:Zip Code:Phone:()
OPTIONAL-Ethnic/racialidentificationandveteranstatus:
TheMissoulaSeniorCorpsissubjecttogovernmentalrecordkeepingandreportingrequirements.Submissionofthisinformationisvoluntaryandrefusaltoprovideitwillnotsubjectyoutoanyadversetreatment.Theinformationiskeptconfidential.
Hispanic/LatinoAmericanIndian/AlaskanNativeAsianAfricanAmerican
NativeHawaiian/PacificIslanderCaucasianVeteran
Whilewemakeeveryefforttomatchtheskillsofthevolunteertotheneedsoftheprogramsoragenciesrequestingtheassistanceofvolunteers,wecannotguaranteeplacements.Allqualifiedapplicantswillreceiveconsiderationforplacementwithoutregardtorace,religion,color,sex,age,sexualorientation,nationalorigin,maritalstatus,disabilityorotherlegallyprotectedstatus.
Revised1/2014