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Delaware Health and Social Services » Division of Services for Aging and Adults with Physical Disabilities

Volunteer Ombudsman Application

If you would like to become a Volunteer Ombudsman with the Division of Services for Aging and Adults with Physical Disabilities, please fill out and submit the form below. The Ombudsman Program's Volunteer Coordinator, will contact you after your application has been received.

If you have difficulty viewing or using this form on your browser, or if you have questions about the form itself, please contact us.

Thank you for your interest in becoming a volunteer!

Volunteer Ombudsman Application

* = required field

First Name: *
Last Name: *
Address: *
Daytime Phone Number: *
Evening Phone Number: *
E-mail Address: *

How did you learn about us?
Web Site
Newspaper
Brochure
Long Term Care Facility
Health Care Professional
Family or Friend
Other: (Please specify)

Do you have a valid driver's license? *
Yes
No

Have you ever been employed in long-term care? *
Yes
No

If yes,

Where?
How long?
Job description:

Do you have or have you had a relative living in a long-term care facility in Delaware? *
Yes
No

Do you have or have you had a relative working in a long-term care facility in Delaware? *
Yes
No

Do you serve as a volunteer for any other organizations? *
Yes
No

If yes, please list organization(s)

Please list two personal references

Reference 1

Name:
Address:
Daytime Phone Number:
Evening Phone Number:

Reference 2

Name:
Address:
Daytime Phone Number:
Evening Phone Number:

I can attend training classes:
In the day time
In the evening
Either day time or evening

Nearest long-term care facilities (if known):

Are you interested in "shadowing"? (i.e., joining an experienced volunteer on his/her rounds in a long-term care facility)
Yes
No
Not sure yet

I am interested in volunteering for this program because:

Comments/Additional Information

Last Modified: 1/10/2008

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