OPG Application

Additional Information
Are you a Veteran?*

YesNo
If yes, which branch of service?
Do you speak any languages other than English*

YesNo
If yes, please list:

PHOTO RELEASE
I authorize the Oregon Public Guardian and Conservator to use pictures of me for the purposes of recruiting volunteers and program outreach. These photos will not be sold or released to any other third party.I do not authorize the Oregon Public Guardian and Conservator to take my photo.
Signature*

Clear
Date*

MonthDayYear
Date

EMERGENCY CONTACT INFORMATION
Name*

First NameLast Name
Relationship:*
Phone Number*

REFERENCES

Please include four professional/non-family references
Reference #1*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*
Reference #2*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*
Reference #3*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*
Reference #4*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*

Please complete the information below, or upload your resumé here:

Cancelof
VOLUNTEER EXPERIENCE
Name of Organization #1
Type of Organization
Job Title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Organization #2
Type of Organization
Job Title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Organization #3
Type of Organization
Job Title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
WORK EXPERIENCE
Employer #1
Job Title
Job Duties
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer #2
Job Title
Job Duties
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer #3
Job Title
Job Duties
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
EDUCATION AND CERTIFICATIONS
Name of School
Area of Study/Major
Diploma/Degree Earned
Name of School
Area of Study/Major
Diploma/Degree Earned
Name of School
Area of Study/Major
Diploma/Degree Earned

FACILITY EXPERIENCE
Have you spent time (as a visitor, employee, volunteer or any other role) in nursing facilities, adult foster care homes, residential care facilities, assisted living facilities, or continuing care facilities?*

YesNo
Facility Name #1
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Facility Name #2
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Facility Name #3
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Comments regarding facility experiences:

Personal Experience
What, if any, is your experience (as a friend, family member, visitor, employee, volunteer or any other role) working with adults with disabilities and/or older populations?*

YesNo
Experience
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Experience
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Experience
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Experience
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role

Consent to Reference and Criminal History Check

The check will assist the Office of the Oregon Public Guardian and Conservator in making an informed decision about candidate qualifications. In assessing the pertinences of a conviction record, the agency will consider such factors as the nature of the crime, when and where it occurred, and the duties of the position for which application is made. The checks will be completed prior to the start of training.

I authorize the Oregon Public Guardian and Conservator to conduct a criminal history check and I agree to provide the office with the information necessary to complete the criminal record check.

I understand that any oral or written statement made during this process that is false, fraudulent, or misleading that is contained in this form or made in the course of any related application process, whether made by me or others at my request, will result in rejection of my application, denial of appointment to a volunteer position or dismissal if discovered after appointment.
Full Legal Signature of Applicant*

Clear
Date*

MonthDayYear
Date

AGREEMENT

I understand that as a Pro Bono Public Guardian or volunteer of the Office of the Oregon Public Guardian Program, I will be working with or exposed to confidential and protected information. I agree to abide by all program policies, National Guardian Association (NGA), federal law and state law related to confidentiality and protected information such as the Oregon Revised Statute governing the Oregon Public Guardian program which states:

ORS 125.685 (3)(d)

… Shall maintain the confidentiality of clients and of written information and materials relating to clients.

NGA Standard 11 ‐ Confidentiality

I. The guardian shall keep the affairs of the person under guardianship confidential.

II. The guardian shall respect the person's privacy and dignity, especially when the disclosure of information is necessary.

III. Disclosure of information shall be limited to what is necessary and relevant to the issue being addressed.

IV. The guardian may disclose or assist the person in communicating sensitive information to the person's family and friends, as defined by the person, unless it will substantially harm the person.

V. The guardian may refuse to disclose sensitive information about the person where disclosure would be detrimental to the well‐being of the person or would subject the person's estate to undue risk. Such a refusal to disclose information must be reported to the court.
Full Legal Signature of Applicant*

Clear
Date*

MonthDayYear
Date
The Oregon Public Guardian and Conservator program retains the right to not approve an applicant for participation in the program or associated training sessions.
Should be Empty:

Oregon Public Guardian (OPG) Volunteer Application

Additional Information

PHOTO RELEASE

EMERGENCY CONTACT INFORMATION

REFERENCES

VOLUNTEER EXPERIENCE

WORK EXPERIENCE

EDUCATION AND CERTIFICATIONS

FACILITY EXPERIENCE

Personal Experience

Demographics Information