JFS COVID-19 CRISIS VOLUNTEER FORM

Full Legal Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Email *

example@example.com

Please enter your full date of birth *

Please identify your race (need for background check) *

Do you give consent to Jewish Family Services of Washtenaw County to conduct a background check? Consent is REQUIRED to volunteer and will not under any circumstances be waived. *

Yes No

Specific to COVID-19 do you identify as, or live in a household with, an "at-risk" member of the population? At-risk includes, but is not limited to, age 60+, or chronic health issues, or immuno-compromised. *

Yes No

Please choose which activities you are interested in volunteering for. *

Well-Being Phone Calls to Community Members (This is 100% remote, by phone, from your home) Food Deliveries (Will involve picking up grocery bags at JFS and driving your own vehicle to drop off food on porches, doorsteps etc.) Packing Food Pantry Bags (Will involve packing grocery bags on-site at JFS, with key JFS team members while social distancing practices will be strictly enforced) Other Errands As Needed (TBD, but could include driving your own vehicle to a pharmacy to pick up individual's medications and drop them off to them, and other miscellaneous similar tasks)

Please confirm your shift availability below. *

Weekday Morning Weekday Early Afternoon Weekday Late Afternoon Weekday Evening Weekend (Saturday or Sunday) Daytime Weekend (Saturday or Sunday) Evening

Online JFS Confidentiality Agreement for Volunteers during COVID 19 crisis

The relationship between Jewish Family Services of Washtenaw County (JFS) and the people it serves is confidential. Protecting that relationship is an essential part of the agency’s obligation to its clients. All JFS volunteers are required to maintain the principle of confidentiality in obtaining and releasing information about clients. Information about clients is made known to volunteers only as representatives of JFS and is therefore to be used only for the purpose of providing services.

Specifically, this means you may not:

- Use a client’s name or other identifying information in any conversation outside the program setting.
- Discuss one client’s problems with another client.
- Describe a client’s case in such a manner that the client could be identified outside the program setting.
- Give out any information, written (including copies) or oral (by phone or in person) to anyone outside the program setting. This includes telling anyone you have had contact with the client.
- No photos or videos of clients are to be distributed by volunteers. This includes photos in any form, electronic, printed, or otherwise.
- Remove any records or papers from the program setting that contains client information without written permission from the client and JFS.
- Access a client’s records, without explicit direction to do so from your supervisor.

Violation of any of the above standards could mean immediately dismissal as a JFS volunteer.

If there is any additional information you feel we should know, please explain below. *

Please confirm your E-Signature. By e-signing, you are stating that all information you provided is true and accurate and that you agree to the above confidentiality agreement. *

Clear