Volunteer Form

Volunteer Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years At Current Address
Home Phone

Area CodePhone Number
Cell/Mobile

Area CodePhone Number
Preferred Type of Volunteering

DrivingOffice HelpHome VisitsTechnology SupportSmall Home RepairsOther
Preferred lead time for request:
Days/hours of the week available:
Months when not available, if known:
Other requests/ interests or limitations in volunteer activity:
Special skills to note:
For Volunteer Drivers and Volunteers performing home visits only:

A Valid driver’s license and automobile insurance is required.
License Number*
License State Of Issue*
Insurance Company
Have you ever been charged with or arrested for an offense or convicted of a crime? If yes, please explain
* Information needed for background and/or driver record check:
Gender

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security Number*
You cannot accept any reimbursement or gratuity, so that your auto insurance is the primary coverage.

Agreed
I hereby authorize Stay at Home in Wilton to conduct a criminal and driving history background check as part of the volunteer application process. I hereby consent to this check being conducted and to the disclosure of the results of such check by the third party performing the check to Stay at Home in Wilton. Further, I hereby release Stay at Home in Wilton, from any and all liability, claims and damages, including but not limited to, claims for releasing or using any information revealed as a part of this check.
Signature

Clear
Date

MonthDayYear
Date
Volunteer Release

I hereby release, indemnify and hold harmless Stay at Home in Wilton and its volunteers (collectively, the “Releasees”) from any and all liability in connection with any injury, death or property damage to me or others including any injury, death, or property damage caused in whole or in part by negligence of the Releasees, in conjunction with the services of Stay at Home in Wilton.

Confidentiality

All volunteers who have access to personal information have a responsibility by which they are bound to Stay at Home in Wilton and its members. Stay at Home in Wilton members act in good faith, expecting that their circumstances and personal matters will remain confidential. Thus, we are obliged to honor this trust.

Though not inclusive, the following is presented to provide some guidelines concerning confidentiality.

1. No identifying information about Stay at Home in Wilton members (names, addresses, social security numbers, physical disabilities, etc.) should be revealed to anyone outside of Stay at Home in Wilton. Identifying information may be disclosed to only those persons and organization for which disclosure of such information is necessary for the welfare of the member.

2. Discussing personal circumstances concerning a member, even though names, addresses or social security numbers are not revealed, is also considered a breach of confidentiality. That is, a volunteer might possibly describe in detail personal circumstances and information concerning a member for whom they have provided volunteer services, and even though the name and address is not revealed, this descriptive material may jeopardize the member’s right to privacy. Thus, the discussion or description of a member’s personal information or circumstances is considered detrimental to the member’s right to confidentiality.

All volunteers are asked to sign the following oath with to respect the confidentiality of all members with whom they come in contact through their volunteer service at Stay at Home in Wilton.

I hereby warrant that I am of full age (18 years old), or if not of full age, that my parent or guardian has given consent for my volunteer work, and approves this release as signed below.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: