COUNCIL ON AGING OF ST. LUCIE VOLUNTEER APPLICATION

VOLUNTEER APPLICATION
Full Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
example@example.com
Phone Number*

Area CodePhone Number
Work Number

Area CodePhone Number

Employment Information
Are you employed?*

YESNO
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number*

Area CodePhone Number
May we contact your employer?*

YesNo

Program of Interest
Please indicate which of our programs that most interest you (descriptions below):*

Nutrition DriverNutrition ServerClerical AssistanceAdult Day CareOther
Please indicate which of our locations you prefer to volunteer at:*

Fort PiercePort St. Lucie
NUTRITION DRIVER VOLUNTEER

This is an opportunity for volunteers to assist in the home delivery of meals. The Nutrition Driver Volunteer will be engaged in tracking and delivering meals to homebound seniors in our community. The assistance of Nutrition Driver Volunteers is a vital part of the success of the Nutrition Program for the seniors of Saint Lucie County. Nutrition Driver Volunteers are provided a mileage allowance to assist in off setting the cost of utilizing their personal vehicle. This opportunity varies in the amount of time required depending upon routes available.

KITCHEN SERVER VOLUNTEER

This is an opportunity for volunteers to assist in the serving of meals to seniors within the
congregate Centers. The Nutrition Kitchen Volunteer will be engaged in tracking, receiving and serving meals to seniors in each of the location meal sites. This also involves the set-up and clean up of the meal sites. This opportunity requires a minimal amount of time (4 hours per day) although volunteers may commit up to 20 hours per week in the program.

CLERICAL ASSISTANT VOLUNTEER

This is an opportunity for volunteers to assist in any administrative department. This may include
filing, data input, organizing and developing files, answering telephones, etc. This opportunity requires a varied amount of time depending upon assignment.

ADULT DAY CARE VOLUNTEER

This is an opportunity for volunteers to deal directly with clients on the Adult Day Care setting at
either facility. The Adult Day Care Volunteer will engage in assisting the Adult Day Care staff in
socialization activities, as well as serving the clients with in the Adult Day Care. This opportunity
requires a varied amount of time depending upon the assignment.

Volunteer Information
Do you have any volunteer experience?*

YesNo
If yes, please explain (where, dates, work performed)
Who referred you to The Council on Aging of St. Lucie, Inc?
REFERENCES

Please provide us with the names of two persons that have known you for at least one
year:

Reference #1
Name*
Address
Phone Number*

Area CodePhone Number

Reference #2
Name*
Address
Phone Number*

Area CodePhone Number
Note: Any volunteer working 20 hours or more per month volunteering with or entering the
home of a client, will be required to have a criminal and abuse background check.
Are you available to work mornings?
Afternoons?
Days available:

Volunteer Staff General Information Form

Please be advised that the following information provided to us by you is strictly
confidential and will not be used in determining your acceptance as a volunteer with the
Council on Aging of St Lucie, Inc.
Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Gender

MaleFemaleI choose not to disclose
Social Security #*
(If the use of a company vehicle is part of your volunteering assignment)
DL #
Issuing State
Upload a copy of DL

Browse Files

Cancelof

Emergency Contact
Emergency Contact Person*

First NameLast Name
Relationship to you?*
Emergency Phone Number*

Area CodePhone Number

Confidentiality Statement
I shall respect the privacy concerns of the people we serve, and I shall hold in confidence
all information obtained in the course of professional service, whether that information is
obtained through written records or daily interaction with the person. Therefore, I will not
disclose an individual’s confidences to anyone, except (1) as mandated by the law; (2) to
prevent a clear and immediate danger to a person or persons; (3) where I am compelled to
do so by a court pursuant to the rules of a court.

No information about a person, or obtained from a person, may be disclosed in a form that
identifies the person, without a written or documented oral consent of the person, or of
his/her legal representative, unless the disclosure is required by a court order.

I shall store or dispose of professional records in ways that maintain confidentiality.

I shall possess a professional attitude which upholds confidentiality towards the people we
serve, colleagues, applicants and any sensitive situations arising within the Council on
Aging of St. Lucie, Inc.

I, upon my termination, shall maintain client and co-worker confidentiality and I shall hold
confidential any information about sensitive situations within this organization.

I understand that violation of this confidentiality statement may be grounds for immediate
dismissal.
Volunteer Signature*

Clear
MonthDayYear

Volunteer Personal Information Release
I give permission for all of my volunteer records (e.g. application, pre-service and in-service training, job descriptions, volunteer interview) which are maintained by the Council on Aging of St. Lucie, Inc., to be released to Area Agency on Aging for verification, inspection and photo-copying.
Your Name
MonthDayYear
Volunteer Signature*

Clear
Please verify that you are human*
Should be Empty:

VOLUNTEER APPLICATION

Employment Information

Program of Interest

NUTRITION DRIVER VOLUNTEER

KITCHEN SERVER VOLUNTEER

CLERICAL ASSISTANT VOLUNTEER

ADULT DAY CARE VOLUNTEER

Volunteer Information

REFERENCES

Volunteer Staff General Information Form

Emergency Contact

Confidentiality Statement

Volunteer Personal Information Release