Before completing this form, please be sure that you have reviewed the volunteer manual and orientation slide show!

Please list THREE non-family members (friend, teacher, employer, clergy, etc) who have known you for at least one year who we may contact as character references.

Fill out the following fields if you will be driving senior care receivers in your car.

Our team works hard to help you get matched with opprotunities that will be a good fit for you.  The following questions are to better assist us with the matching proess.

Pledge of Confidentiality

 I am volunteering my time to help carry out the work of the In Service of Seniors program.  I understand that in the course of my volunteer work and experience I may learn certain facts (including protected health information) about individuals I help that are of a highly personal and confidential nature.  Examples of such information include medical conditions and treatment, finances, living arrangements, employment, relations with family members, etc.  I understand that all such information must be treated as completely confidential.  I agree not to disclose any information of a personal and confidential nature to any person other than In Service of Seniors staff members.

 I have completed the In Service of Seniors volunteer orientation including the Health Insurance Portability and Accountability Act (HIPAA) module and I understand that all personal health information and other information must be treated as completely confidential and is not to be revealed to any unauthorized source.

 Having read this pledge, I understand and agree to abide by the In Service of Seniors policy on confidentiality.

 I understand that failure to comply may result in my immediate dismissal as an In Service of Seniors volunteer.