"In Service of Seniors: North" Volunteer Registration Form

Thank you for registering to shovel snow or do yard work for North Hills Community Outreach's In Service of Seniors: North program.

Before completing this form, please be sure that you have reviewed the snow shoveling or yard work orientation slide show!

First Name*

Last Name*

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Birth Date

MonthDayYear

Gender

MaleFemaleIdentify as other

Ethnicity

Emergency Contact Name

Emergency Contact Phone Number

Area CodePhone Number

Your Current/Previous Employer

Please list current or previous volunteer activities

Your Current/Previous Occupation (please note if you are retired)

If 18 years or younger, please list the name of your parent, guardian or other adult who will be accountable for your volunteer work.

Are you a veteran of the armed forces?

YesNo

How did you hear about In Service of Seniors: North? (check all that apply)

North Hills Community Outreach (NHCO) websiteNHCO social media post (Facebook, Twitter, etc)NHCO newsletter or emailNewspaper or MagazineRadio or TelevisionPoster or FlierHeard from a friendUnited Way or Open Your Heart to a Senior website, email or social media siteOther/Can't Remember

How will you most likely travel to your seniors?

CarBusWalk/Bike

Please list any physical limitations or medical conditions of which you would like us to be aware.

Signature required*

1. By signing below, you confirm that the above information is accurate, that you have viewed the volunteer orientation slideshow, and that you understand all written and verbal information.

2. Pledge of Confidentiality

I am volunteering my time to help carry out the work of the In Service of Seniors program. I understand that in the course of my volunteer work and experience, I may learn certain facts (including protected health information) about individuals I help that are of a highly personal and confidential nature. Examples of such information include medical conditions and treatment, finances, living arrangements, employment, relations with family members, etc. I understand that all such information must be treated as completely confidential. I agree not to disclose any information of a personal and confidential nature to any person other than In Service of Seniors staff members.

I have completed the In Service of Seniors volunteer snow shoveling orientation and I understand that all personal health information and other information must be treated as completely confidential and is not to be revealed to any unauthorized source.

Having read this pledge, I understand and agree to abide by the In Service of Seniors policy on confidentiality.

I understand that failure to comply could result in my immediate dismissal as an In Service of Seniors volunteer.

Signature required. Sign here (use your mouse or touch pad). If 18 years or younger, a parent/guardian/adult in charge must sign.*

Enter the message as it's shown*

In Service of Seniors: North SNOW SHOVELING or YARD WORK Volunteer Registration Form