OLIVER LODGE SPECIAL CARE HOME Volunteer Services Department – Registration Form First Name Last Name Home Address Postal Code Home Phone Number Cell Phone Number Work Phone Number Occupation Birth Date E-Mail Address Is there any pertinent medical information of which we should be aware? YesNo If yes, please explain. Emergency Contact Phone Number Relationship to you How did you hear about Oliver Lodge? Do you have experience working with the elderly? YesNo Explain Do you have any special skills, interests, hobbies or training? In what type of activities have you volunteered your services in the past? We ask for a minimum commitment of 24 hours. I agree to commit my services for.... 4 months6 months1 yearTwo to four hours per weekOnce per monthOnce in a while Most programs are scheduled at least a month in advance. Recreation calendars are available in the Volunteer Room. Please indicate the days and times you are available for volunteering. SundayMorningAfternoonEvening Monday MorningAfternoonEvening Tuesday MorningAfternoonEvening WednesdayMorningAfternoonEvening ThursdayMorningAfternoonEvening FridayMorningAfternoonEvening SaturdayMorningAfternoonEvening Confidentiality Agreement I agree to hold in strict confidence all information concerning residents of Oliver Lodge Special Care Home and agree not to discuss these matters with anyone other than those properly concerned. I am aware that should I violate this confidence I may be asked to resign my position as a volunteer. Date Δ
