Volunteer At Girard-Battles Village

Name	(First, Middle, Last)
Address
City
State
Zip Code
Home Phone
Work Phone
Birth Date
Email Address
Education
Community/Club Affiliations
Have you ever been employed by Presbyterian Homes?	Yes NO
If Yes, Name of Facility

Name
Phone Number

Health Condition	Excellent Good Fair Poor Please check one
Name of Family Physician
Phone # of Family Physician
Any Significant allergy, illness or disease you would like to make us aware of
Any Lifting or other health restrictions?

Any current or prior experience volunteering?
Special Skills/Hobbies/Interests
Days you are available	Monday Tuesday Wednesday Thursday Friday Saturday Sunday Check all that apply

Do You Prefer:	1:1 Interaction with Residents Group Activities with Residents Other Check all that apply
What kind of volunteer work are you most interested in?
Are you willing to help in the event of a disaster?	Yes No Check one
Please list any skills that would be helpful
Check any that you would be willing to help with:	Feeding Residents Pushing Wheelchairs Sitting with a Resident Answering our Phones Being a Greeter at the Door Working in the Kitchen Assisting Housekeeping Assisting Laundry Helping in Maintenance Department Helping with resident Care End of Life Compaionship Check all that apply

I understand that this facility respects residents’ rights with regard to privacy of information and I agree to respect these rights in the performance of my volunteer duties and keep “professional” confidentiality in all my statements outside the facility; and I agree to respect residents’ rights to privacy, as well as those of the family and the facility when out in the community or socializing with others. I have received and understand the Resident Rights.
If selected to participate in Presbyterian Homes’ volunteer program, I agree to abide by the established rules and regulations of the facility.
I understand my volunteer relationship can be terminated at any time, at either the option of the facility or myself.
I understand that any person volunteering 2 hours a month or more will be included in the Employee Health testing for Tuberculosis.

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