Volunteer Ombudsman Application

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,

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