The Washington Home - Volunteering

Date (Month/Day/Year)
Name
Check one: Mr. / Mrs. / Ms. / Miss
Address
City
State
Zip
Home Phone
Work Phone
E-Mail Address
Occupation
OR Student: Jr. High / High School / College (Check One)
Employment History
Education/Training
State of Health: Excellent Good Fair Poor
Do you have any physical handicap or special physical needs? Yes No
If yes, please describe
Notify in case of Emergency:
Name
Address
Telephone
Briefly state your reason for wanting to volunteer in a Long-Term Care Health facility:
Skills/experience:
References: Please list below two people (NOT family members) we can contact as references:
Name
Address
Phone
Relationship
Has known you for how long
Name
Address
Phone
Relationship
Has know you for how long
Optional Information:
Birthday (Month/Day/Year)
Ethnic Background
Availability:
• Can you volunteer an average of three hours per week? Yes No
• Can you give an additional 2 hour period twice a year for in-services or group meetings? Yes No
• Can you promise a full year of service OR if a student at least 30 hours of Community Service? Yes No
If you answer NO to any of the above, please explain:
Please enter in the HOURS you are available to volunteer:
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Work Preference: Friendly Visitor Activity Assistant Meal Time Assistance Activity Leader Medical Escort Office Support

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The Washington Home is a non-profit, 501(c)(3) organization that provides our residents with the highest standards of care possible.
The Washington Home is accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).