Preakness Healthcare Center Phone: (973) 585-2140 Fax: (973) 790-1903 VOLUNTEER APPLICATION Name: of Birth: Address: County: Telephone: (H) (W) (C) Email: Education: (High School, College, Degree) Occupation (if Applicable): Special Skills/Hobbies/Areas of Interest: Previous Volunteer Experience: If representing a Church, Synagogue, Community Organization or School, please indicate name, address and contact person: Are you volunteering for school credit or probation community service: How did you hear of Preakness Healthcare Center? Have you ever been convicted of a crime? Yes No I will notify Volunteer Services or my direct contact person if I am unable to fulfill may Volunteer assignments. Volunteer Applicant Signature I, hereby give permission for my son/daughter to join the Volunteer Program at Preakness Healthcare Center. I realize the responsibility of the organization and will cooperate with him/her to comply with its regulations, including transportation. Parent/Guardian Signature (if applicant is under 18)
VOLUNTEER ACTIVITIES o Transporting residents to activities, religious services, physical therapy. o Serving as a Friendly Visitor to residents. o Assisting residents to recreational activities. o Other Monday Tuesday Wednesday Thursday Friday Saturday Holidays AVAILABILITY Days AM PM FOR OFFICE USE ONLY Interviewed by: Assignment: : Dept: Start : Resigned: Total Hours Served: Identification Badge Ordered: Received: Orientation (s): Attended: Yes No References Sent: Received: Awards Received: Special Notes:
Name of Volunteer: I hereby authorize the person listed below to provide a reference for me including any information pertinent to past performance and character. Applicants Signature Name of Reference Telephone Number Address City County Zip Code Dear Sir/Madam: Your name had been provided as a reference for the above named individual who has applied for Volunteer Service at Preakness Healthcare Center. A prompt reply to the address above is appreciated and will assist in placing this person within the facility. ALL INFORMATION WILL BE REGARDED AS CONFIDENTIAL. 1. How long have you know the applicant? 2. What is your relationship to the applicant? 3. Please comment on any experiences that you have had with the applicant which relate to the position being considered? 4. Does the applicant have any special qualifications or limitations? Signature of Reference/Title Telephone Reference? Yes No
PLEDGE OF CONFIDENTIALITY VOLUNTEER SERIVCES As a Preakness Healthcare Center Volunteer, I will respect the confidentiality of any Resident s information to which I might be exposed and will in no way divulge this information to any other person inside or outside the Healthcare Center. Signature of Volunteer
I understand that: Office of Volunteer Services Policies, Procedures and Responsibilities The goal of the volunteer is to provide volunteer services where and when they are needed. The department s policies and procedures apply equally to all volunteers. The minimum age for volunteering is 14. Prior to beginning volunteer service, I am required to complete all necessary forms and complete orientation session(s) to become familiar with goals, services and policies of Preakness Healthcare Center. No volunteer will be assigned to assist in the office or on the unit of a family member. Preakness Healthcare Center staff members do not volunteer in their own offices or on their own units. I am required to wear my identification badge and meet acceptable dress codes at all times. I am to account for all volunteer hours served in required Sign-In-Book and am expected to sign in immediately prior to beginning volunteer service and sign out at the completion of service as I am leaving the building. Information records are maintained on each volunteer. I should call the volunteer office if I am unable to report to my assignment. Meals will be provided for volunteers who provide 4 or more hours of service. Official Volunteer Recognition is provided annually. Preakness Healthcare Center is a smoke-free environment. Visitors, staff and volunteers are prohibited from smoking in the facility. Lectures including Infection Control, Fire Safety and Residents Rights/Confidentiality are provided annually and I am responsible for understanding the information given. If I am injured on the premises, I should report it immediately to my supervisor and to the Coordinator of Volunteer Services. An accident/incident report must be completed.
I am only to provide services for which I have been trained, in designated areas arranged by my supervising department. It is important to use only equipment designated by my immediate supervisor and considered appropriate and necessary to my position. I may not witness documents for a resident or hold money or anything else belonging to a resident. I should never accompany a resident off Preakness Healthcare Center grounds unless specific arrangements have been made with the Social Services, Nursing and/or Therapeutic Recreation departments. I should not bring food to any resident without checking first with the Nursing Supervisor regarding dietary restrictions and agency regulations. I should not bring prescription or over the counter products to any resident or provide any medical care to any resident. I must not accept food or gifts from residents at any time. I must understand wheelchair regulations before attempting to transport a resident. I must honor residents requests for non-participation in activity and report such requests to a Nursing or Recreation Supervisor. I must not feed, toilet or lift a resident. I must deal tactfully with personnel, residents, family members, visitors and other volunteers. I understand that there is no soliciting or canvassing permitted at Preakness Healthcare Center. I acknowledge that I have received the Volunteer Manual and have reviewed the information with the Coordinator of Volunteer Services. I understand the information and agree to abide by the rules and regulations as set forth in the manual. I also understand that as policies change, changes will be communicated to me. I understand that I can be suspended or released from Volunteer Service at any time at the discretion of the Coordinator of Volunteer Services based upon the needs of the facility and the Coordinator s personal judgment. VOLUNTEER S SIGNATURE DATE