Nursing Home Volunteer Application Form – Fill Out and Use This PDF

Enter Today's Date and how you hear about the program.

Under Contact Information, print your name.

Under Contact Information, list at least one phone: Home or Cell/Work.

Under Contact Information, enter the Address: Street, Apt. #, City, State and Zip.

Under All About You, list your age if you are under 20 years old. Then list Special skills (hobbies, languages, etc.), Past volunteer experience and Past experience with the elderly.

Under Emergency Contact, enter the Name, Relationship and Phone.

Mark Yes or No for Are you volunteering to complete Community Service Hours? If yes, enter how many hours you need, in total, and by what date the hours are required to be completed. For what purpose are you required to perform community service? Mark School, Service Club/Organization or Other. Court mandated community service positions are not available.

Check the volunteer opportunities you may be interested in. Group Programs: Arts & Crafts, Parties, Games, Sing Along, Religious, Current Events, Gardening, Fitness, Reading Groups. One to One / Small Group Interactions: Friendly Visits, Letter Writing, Trivia, Reminiscing, Reading, Sensory Stimulation, Manicures, Board Games. Independent: Musical Performance, Educational Talks, Leading Resident Groups (Men's Club, Current Events, Sewing Group, etc.). If you check Leading Resident Groups, enter what kind of group you would like to lead.

Check off your times of availability on the chart: Mornings, Afternoons and Evenings.

How frequently are you planning to volunteer? Check Just this once, Daily, Several times a week, Once a week, Several times a month or Once a month.

You sign on the line after Please Sign Here.

After filling out this application, return it to the front office. The Volunteer Coordinator will contact you once your application has been processed.