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.

References

Please list three complete references including volunteer and work experience, if any. All references listed will be contacted.

Volunteer Placement Preference & Availability

Please list 1st, 2nd, 3rd, and 4th choices. Volunteer position availability varies based on need.

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.)

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.

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 Here

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!

HIPAA Training & Test

Read the following HIPAA Training document and then complete the quiz below.

HIPAA Training

I have completed the HIPAA privacy training and I agree to follow ADRC of Brown County's privacy and confidentiality policies.