First name:   

Last name:

E-mail Address:

Phone:   

Work Phone:

Address:

City:

State:

Zip Code:

Date of Birth

Month January February March April May June July August September October November December   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year:

Ethnicity (Optional):

Occupation/Place of Employment:

Previous Work Experience:

Special Skills/Hobbies:

Community Affiliations:

Previous Volunteer Experience:

Are you bilingual? If yes, what language:

Physical Limitations/Health Concerns Including Allergies:

Have you ever been convicted of a felony:

Yes

No

If yes, please explain:

Opportunities that Interest Me:

Companion Volunteer/Friendly Visitor

Shopping

Transportation

Light Housekeeping

Sharing Recreational Activities

Volunteer with DDRC Recreation Dept.

Helping with one-time requests such as Minor Home Repair, Yard Work, Packing Boxes

Office Volunteer

Respite (providing caregiver a break)

Personal Business (mail and paperwork)

Friendly Phoning

Art Mentor

Other

Areas in Jefferson County you are willing to serve:

Central

North

South

East

West

Days

Evenings

Weekends

Name:

Relationship:

Day Phone:

Evening Phone:

Physician:

Physician Phone:

Please list TWO names of person not related to you whom you have known at least one year and include phone numbers and addresses.

Reference name:

Reference Phone:

Reference Address:

Reference 2 name:

Reference 2 Phone:

Reference 2 Address:

Do we have your permission to use your name or picture in newsletter articles and media releases? (required)

Yes

No

Please tell us why you want to be a volunteer:

VOLUNTEER CONFIDENTIALITY AGREEMENT

While volunteering, one may receive a certain amount of information about the person with whom they are working. This information is considered confidential.

The State of Colorado has strict regulations governing the disclosure of confidential information. In general, information about the person with whom you are working may not be released publicly by the agency or any representative of the agency (including volunteers), unless this person or his/her legal guardian gives written authorization.

Information, which is considered confidential, includes, but is not limited to, name, address, phone number and any information concerning the person’s disability or the services they receive. Any information pertaining to the person’s family is also considered confidential.

Developmental Disabilities Resource Center also complies with the Federal Regulations HIPPA (the Health Insurance Portability and Accountability Act) which specifically protects the DDRC consumer’s health information.

If you have any questions, please call DDRC (303-233-3363) and ask for Volunteer Services or the Development Department.

I have read the above statement and agree to maintain the confidentiality of those with whom I work.

I agree: