HILLVIEW HEALTH CARE CENTER

VOLUNTEER APPLICATION
 

I.   Name        Date: 
  (Last) (First)  
      
     Address:   
     Home Phone:     Best Time To Call:   
     Emergency Contact (name and phone number):   
     Relationship:  
   
     References: (non-relatives; list names, address, and phone; students - list your instructors);  
      
     1.     2.  
             
   
II.  This section for college students only.  
   
School:      Major:   
Class requiring volunteer hours:     Hours required for classwork:  
   
III. Frequency with which you wish to volunteer. (check preference)  
   
  Weekly (1,2, or 3 days)                   Every Other Week   Weekends Only  
       
  Monthly   Other:  
       
IV. Time Preference/Skills/Abilities. (check preference)  
   
Mornings:  Afternoons: Evenings:  
9:00 a.m. - 1:00 a.m. 1:00 p.m. - 4:00 p.m. 6:00 p.m. - 8:30 p.m.  
   
ALL VOLUNTEERS MUST GO THROUGH A 1-HOUR ORIENTATION SESSION.  
   
Days of the Week Preferred:  
   
Any skills, hobbies, or previous experiences you would like to share:  
 
   
Any physical limitations:  Yes   No  
   
If yes, please explain:  
 
   
I understand that it is my responsibility to keep confidential any information I learn about the  
residents and/or their family, and that violating confidentiality is cause for immediate dismissal.
   
Signature: _________________________________________
   
   
V.  Possible Areas of Work Preference (Please mark your preferences.)  
   
Help with Parties  
Provide Instrumental Talent  
Provide Vocal Talent  
Help In Making and Putting Up Decorations  
Taking Residents for Walks/Rides/Outings  
                   With Staff       Without Staff  
Transporting Residents To Activities  
Helping To Prepare for Special Events (Christmas, Halloween, Valentines, etc)  
Book Cart (Distributing Books/Magazines/Puzzles)  
Play Music/Read/Simple Games for Room Bound Residents  
Help With Programs for Low Functioning Residents (Creative Stimulation, Lounger Program)  
Work with the Resident Rooms  
Teach a Special Talent  
Assist During Craft Projects/Woodworking  
Friendly Visits to Residents Rooms  
Letter Writing  
Outdoor Gardening  
Assist Exercise Group  
Ladies Fingernail Painting  
Help During Pop Corn Days  
Bulletin Board Ideas  
 

 

 

 

 

 

   
Rev. 10/01