Volunteer Application Page - The Span Center

Volunteer Application

Name(Required)

Preferred Name

Date of Birth(Required)

*Volunteers under 18 must be accompanied by an adult

Home Phone

Cell Phone

Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Experience/Interests:

Current Employer (if applicable):

Previous Employer:

Volunteer Experience

Education

I'd like to volunteer for the following (Check as many as you'd like):

*Clerical Assistant: Assists with office duties including data entry, filing, mailings, and answering phones. (Limited availability.)

*TeleBridges: (Minimum One Year Commitment). Provides friendly reassurance phone calls to older adults 1-2 times per week, by offering a listening ear and an encouraging word. (Limited availability.)

*Volunteer Money Management (Minimum One Year Commitment). An in-home check writing and financial management service for people 60 and over. Most people served by this program are low income or disabled and are having difficulty meeting monthly expenses.

* Indicates a background check is required

VICAP

Counselor: Provides one-on-one assistance navigating Medicare and related health insurance.

Part D MIPPA Specialist: Helps people navigate Medicare prescription drug coverage in one-on-one or group education sessions. 4 hours a week (with some flexibility) between September 15 & December 15.

VICAP Administrative Assistant: Provides program support, including data entry and clerical duties.

*VICAP: (VA Insurance Counseling and Assistance Program) (Minimum One Year Commitment). Counsels on Medicare, Medicaid, supplemental and long-term care insurance issues. Provide information, assistance and referral services to callers on an information hotline. (Check first for availability). *VICAP: +Please note: Insurance agents, employees and brokers, and financial planners are not eligible to serve as VICAP Volunteers.

*Please note: Limited Unpaid Internships are available for some programs. If interested, please check here, and indicate your program of interest-even if it’s not listed here.

I am interested in an internship

Internship Program of Interest:

College/University:

Other Program/Topic of Interest:

Please check any of the following special skills or interests that you have:

Foreign Language

If you speak a language other than English, please list it here.

Other:

If you have other skills you would like us to know about, please list them here.

Availability

I am interested in:

Short Term Volunteer Commitment – Less than three months

Long Term Volunteer Commitment – Minimum one year

How many hours per month would you like to volunteer?

This does not have to be exact but it can help give us a general idea.

Which days of the week and hours would you prefer to volunteer?

Please let us know which days of the week and which hours fit your schedule

Do you have reliable transportation if needed for your volunteer position?

Yes

Do you have geographic limitations, and if so, what are they?

Why would you like to volunteer for The Span Center?

How did you learn about volunteer opportunities at The Span Center?

If via the internet, which website?

Optional

Do you have any medical conditions you would like The Span Center to be aware of?

Yes

If yes, please describe:

Do you require any special accommodations?

Yes

If yes, please describe:

Emergency Contact

In case of an emergency, please contact:

Phone

Relationship

References:

For references, please list ONE personal and ONE professional- someone who is familiar with your character and/or work with other organizations) Contacts can be Work, Volunteer, Clergy. Please do NOT use relatives. Please inform them that a letter will be sent to them from this office. *Incomplete applications will not be accepted.

Personal Reference

Name

First Last

Phone

Professional Reference #1

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Professional Reference #2 (*Please list a second professional contact ONLY if you’re interested in Money Management.)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

I understand that the references listed above will be contacted and that The Span Center will complete a record check on qualified applicants. I consent to the release of all relevant information concerning my ability and fitness to work as a volunteer. I certify that the information given herein is accurate to the best of my knowledge. I understand that this information will be held in confidence and not released to any other person or agency.

I Understand

Demographic Information

Because we receive federal funding for our volunteer program, the Department for Aging and Rehabilitative Services (DARS) requests we ask the following demographic information to verify we serve all populations equally. The Span Center respects your privacy rights. Please provide only the statistical information you wish to release to assist in our compliance with Volunteer Program Service Standards. Contact us at 804-343-3024, if you have questions.

How do you identify?

Female

Male

Other

If Other, how would you like to be addressed?

Race

African American/Black

Alaskan Native

American Indian

Asian

Hispanic

White

Unknown

Is there one member in your household, whose annual income above 15,650?

Yes

Are there two members in your household, with an annual income above $21,150?

Yes

Are there there three members in your household, with an annual income above $26,650?

Yes

Are there there four members in your household, with an annual income above $32,150?

Yes

Are there five or more members in your household?

Yes

If so, how many?

Nature of Volunteer Service: The Span Center relies upon volunteers and paid staff to provide assistance to area residents. The scope of responsibilities varies for each volunteer, based on the program chosen. I understand that as a volunteer of The Span Center:

• I must submit monthly documentation of my activities to the Volunteer Program Manager. • Volunteers provide services free of charge to any clients who seek assistance from the program.

Confidentiality/Non-Conflict of Interest: Volunteers of The Span Center cannot promote private or personal interests as they go about performing the duties described in position descriptions, policies, and program guidelines. To comply with this requirement, I agree to the following:

I understand that I could have access to certain personal information about my clients, including medical, insurance, financial and other data of a sensitive or confidential nature.

I agree to keep such information confidential and to use it only to perform my volunteer duties, to the extent that a client explicitly authorizes, or as directed by my Volunteer Program Manager.

I will not disclose or use confidential or other personal information obtained from a client through my association with The Span Center for personal gain or the gain of my employer or any other party.

I agree to respect the confidentiality of my clients and to exercise good faith and integrity in performing my volunteer duties.

I agree not to use any client contact information obtained while volunteering to solicit clients or business for myself or others. Volunteer solicitation of clients is not permitted.

Volunteer Agreement: As a volunteer with The Span Center, the Capital Area Agency on Aging), I agree to act within the scope of my responsibilities and abide by all program policies and procedures as specified in, but not limited to the following: position descriptions, handbooks, manuals, orientation and training, and other guidance.

The Span Center is not responsible for any activity that I engage in or any responsibility that I assume other than those specified in the above-mentioned program policies and procedures. Any action that I take outside the scope of responsibilities for my position will be taken at my own personal risk. I release The Span Center, staff, board members, and affiliates from any and all liability or responsibility for any accident or injury.

Typing your name below affirms that you have read, and agree to the statements listed above.

Name

First Last

Next Steps: (not necessarily in this order.

1. Receive an email or call from Volunteer Staff 2. Informal Interview-determining your expectations and sharing ours 3. Possible contact with manager of your program (s) of choice 4. Volunteer Staff sends form to your references 5. When favorable references are received, background check link is sent from our vendor. 6. Volunteer Orientation 7. Program Training

* Volunteer Services will be in touch with you throughout the application process, but please be advised, completing an application does not guarantee acceptance into the volunteer program.

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