I am interested in the following programs (please check all that apply): PAVE (Personal Advocacy Volunteers for the Elderly) CAVIAR (Creating a Voice for Institutionalized Alzheimer’s Residents) LTC Ombudsman Name: * Home Phone: Cell Phone: E-mail: Address: City, State, Zip Code: How do you prefer to be contacted? Phone Email Mail How did you hear about us? Date: When are you available to start? Do you have available transportation? Yes No How many hours per month are you interested in volunteering? * 1-5 6-10 11-15 More than 15 No preference Do you or a family member work in or own a nursing home or residential care facility? Yes No if yes, where? Is a member of your family in a nursing home at the present time? Yes No if yes, where? Have you ever been convicted of a crime? * Yes No if yes, please describe: Why are you interested in volunteering with us? * Have you ever volunteered before? * Yes No If yes, please describe your most recent experiences: Describe any personal or professional experience you have had with older adults: Describe any education or training you have received: Are you a member of any civic/professional/fraternal organizations? Yes No if yes, please describe: Describe any special skills or interests: Date: References (please list at least two, with one being professional): 1. Name: * Relationship: * Phone: * E-mail: OK to contact this person? Yes No 2. Name: * Relationship: * Phone: * E-mail: OK to contact this person? Yes No 3. Name: Relationship: Phone: E-mail: OK to contact this person? Yes No Date: I certify that all information provided in the application is true and accurate. * Date: Type this code: (no spaces) *