Volunteer Application NOTE: This form is not compatible with Internet Explorer (IE). Please use another browser, such as Mozilla, Chrome, or Edge. Step 1 of 12 8% Thank you for your interest in volunteering at the Aging & Disability Resource Center. There is always a need for volunteers to assist older persons and adults with disabilities to lead dignified, independent lives. You can be assured that your services will mean a great deal to the people you serve. Whatever your passion is, whether you can assist on a regular on-going basis or as a substitute when you can, your volunteer services will be greatly appreciated.Please complete and submit the following: Volunteer Application Confidentiality Statement & Conflict of Interest Background Information Disclosure Annual HIPAA Training Copy of Driver's License Cop of Proof of Auto Insurance (or Declaration Page) NOTE: ADRC is required to have on file, up-to-date proof of insurance coverage for all volunteers. You will be mailed a request for updated proof of insurance biannually or annually. The copy of the insurance card must show the expiration date for your current policy. If it does not, you may call your insurance agent and ask them to send us a “Certificate of Insurance”. (We can make copies of your driver license and proof of insurance if you bring them to ADRC).What happens next? We will run your background check and contact your references. Once all of these items are obtained, we will contact you via phone or by mail with the status of your application. Volunteer Applicant InformationDate(Required) Full Name(Required) Address(Required) Apartment/Unit # City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code(Required) Phone Number(Required) Phone Type(Required) Cell Landline May we text you? Yes No Email Address Emergency Contact Name & Relationship(Required) Emergency Contact Phone Number(Required) Education - Certifications - LicensesPlease include all certifications, licenses, and/or education you may have:Are you fluent in a second language? Yes No What language? References Please list three complete references including volunteer and work experience, if any. All references listed will be contacted.Full Name(Required) Years Known(Required) Relationship(Required) Phone Number(Required) Full Address(Required) Email Full Name(Required) Years Known(Required) Relationship(Required) Phone Number(Required) Full Address(Required) Email Full Name(Required) Years Known(Required) Relationship(Required) Phone Number(Required) Full Address(Required) Email Previous EmploymentCompany Phone Address Supervisor Job Title ResponsibilitiesDates Employed Military ServiceBranch From To Rank at Discharge Type of Discharge If other than honorable, please explain Volunteer Placement Preference & Availability Please list 1st, 2nd, 3rd, and 4th choices. Volunteer position availability varies based on need.Volunteer Interest1st Choice2nd Choice3rd Choice4th ChoiceNot InterestedMeal DeliveryDining Site AssistantHomebound Meal PackagingGrounded Café Food PrepTechnology InstructorAdvocacy/FundraisingPrevention Health Class LeaderForeign LanguageProgramming/EventsMedicare OutreachMarketing & DesignClass LeaderVolunteer InterestOther InterestsSpecial Talents, Hobbies, or SkillsPlease list all restrictions & limitations(Reasonable accommodations for disabilities are available. Please request here if needed.)Day(s) of the Week Available Monday Tuesday Wednesday Thursday Friday Saturday Time(s) Available Do you drive/have a vehicle?(Required) Yes No Vehicle Insurance Information I understand that if I use my personal automobile in my Volunteer Service, I will arrange to keep in effect automobile liability insurance equal to the minimum limits required by our state. (Please upload a copy of your insurance card or "declarations page" or have your insurance agent send us a "Certificate of Insurance" of your policy.)Driver's License # License Plate # HiddenHow would you like to submit your documents? Upload online Drop off at ADRC Upload a copy of your drivers license hereMax. file size: 300 MB.Upload a copy of your auto insurance card or "declarations page" hereMax. file size: 300 MB. Please read the following statement before signing I hereby authorize the Aging & Disability Resource Center to contact the references listed on this form. I hereby authorize said agency to investigate my background and character, whether this information is of public record or not. I hereby authorize the Aging & Disability Resource Center to conduct a driver license check, if applicable. I certify that my statements in this application are true, complete and correct to the best of my knowledge and belief and understand and agree that any misstatements or omissions of fact on this application constitutes grounds for rejection or termination from this volunteer program. I hereby irrevocably consent to and authorize the use and reproduction by the Aging & Disability Resource Center of Brown County, or anyone authorized by them, of any and all photographs which they have taken of me, for display, publication, publicity or any other purpose whatsoever without my name, without compensation to me, and without further inspection by me.Signature(Required)By typing your name, you are electronically signing this form. Commitment to Non-Discrimination In accordance with Civil Rights Compliance Standards, you will not be denied services or discriminated against because of religion, age, race, sex, disability, physical condition, sexual orientation, or developmental disability. Reasonable accommodations will be made for disabilities in accordance with the Americans with Disabilities Act. If you require such an accommodation, please contact the Aging & Disability Resource Center 72 hours prior to the need for the accommodation. If you are denied services for any reason and would like to file a grievance form, you may receive a copy of this form by calling (920) 448-4300. Call 711 Relay for hearing impaired TTY assistance. The Aging & Disability Resource Center is an equal opportunity employer and provider acting under an affirmative action plan. As a representative of the Aging and Disability Resource Center of Brown County, by signing below, I authorize I have reviewed and received training on the ADRC’s Confidentiality and Conflict of Interest Policies, and agree to comply with its provisions. If I do not fully understand these policies or how they are relevant to my employment or association with the ADRC, I will not sign this statement until I have spoken with the ADRC Director, and I understand these policies. I acknowledge the obligation of ADRC staff to be objective, customer-centered and independent of Managed Care Organizations (MCOs), IRIS Consultant Agencies (ICAs) and other providers or services to which customers could be referred. I acknowledge that I will be required to review the Conflict of Interest Policy, Confidentiality Policy, and HIPAA Training on an annual basis.Confidentiality & Conflict of Interest Please read the document at the following link before signing. Click HereSignature(Required)By typing your name, you are electronically signing this form. Background Information Disclosure Form A Background Information Disclosure form will be sent to you after you complete the volunteer application. This will need to be completed and returned before your application can be processed. Thank you!HiddenHow would you like to submit this document? Upload online Drop off at ADRC HiddenUpload completed Background Information Disclosure (BID) form here(Required)Max. file size: 300 MB.HiddenAdditional BID form docs (if needed)Max. file size: 300 MB.HiddenConfirmation(Required) By checking this box, you understand that you need to upload your Background Information Disclosure form before submitting. If this form is not uploaded, your application will not be processed. HIPAA Training & Test Read the following HIPAA Training document and then complete the quiz below. HIPAA TrainingHIPAA Training TestWhich of the following may be an example of potential PHI violation?(Required) PHI faxed to the wrong place PHI left unattended or unsecured Discussing PHI in a public space Sharing or accessing information without a "need to know" All of the above Who do you report a potential PHI violation to?(Required) Another volunteer The media Your program supervisor or the Volunteer Coordinator Your friend or spouse What does HIPAA stand for?(Required) Healthy Information Program Access Administration Health Insurance Portability and Accountability Act Health Internal Privacy Administration Act None of the above True or False: It's alright to look up an ADRC customer PHI information even if it's not part of my volunteer job duties.(Required) True False Which is true if I am involved in a HIPAA violation?(Required) A. I have no personal liability B. I may be liable for civil penalties from $100 to $50,000 per violation and up to $1.5 million per year C. I may be subject to criminal penalties from $50,000 and one year in prison to $250,000 and ten years in prison D. Both B and C I have completed the HIPAA privacy training and I agree to follow ADRC of Brown County's privacy and confidentiality policies.Signature(Required)By typing your name, you are electronically signing this form. 35595
