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* Today's date:

Date
PERSONAL INFORMATION

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* First name:

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* Last name:

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* Email Address:

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* Home Address

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* Phone Number

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* Date of Birth

Date of Birth
EMERGENCY CONTACT INFORMATION

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* Emergency Contact Name

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* Relationship

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* Contact Phone

EDUCATION
EMPLOYMENT INFORMATION

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* Current Place of Employment:

PREVIOUS VOLUNTEER EXPERIENCE AND SPECIAL SKILLS

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* 1. Volunteer Organization Name

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* Duties

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* 2. Volunteer Organization Name

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* Duties

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* Special Skills/Interests

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* Languages Spoken

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* Languages Understood

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* Explain why you are interested in volunteering for Meal Partners

REFERENCES
We require and check references for all volunteers.  Please list two people (no relatives please) who would be willing to serve as references for you.  Please make sure all information is complete.

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* 1. Reference Name

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* Relationship

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* Contact Phone

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* Email

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* 2. Reference Name

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* Relationship

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* Contact Phone

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* Email

AVAILABILITY
Your willingness to to be flexible regarding location of survivor increases our ability to make a compatible match.   

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* Please select all the cities you would be willing to visit a survivor in

VEHICLE INSURANCE INFORMATION
Occasionally volunteers may provide transportation, go shopping for a visitee or run other errands as part of their volunteer assignment.  Jewish Federation and Family Services carry special volunteer insurance that covers volunteers while they are performing services on behalf of the agency.  However, volunteers must have on file proof of their own insurance coverage (please provide a copy of proof of auto insurance coverage and a copy of your driver's license to JFFS) before providing any of the above services.  This insurance is primary coverage with Jewish Federation and Family Services providing secondary coverage.

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* Car Insurance Company

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* Policy #

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* Phone

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* Driver's License #

MEDICAL INFORMATION

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* Are there any health issues that you need to make us aware of that might effect your ability to perform volunteer duties?

LEGAL DISCLOSURES

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* Other than minor traffic offenses, have you ever been charged or convicted of a felony or any other serious offense or incident?  A background check will be performed on all potential volunteers.

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* If yes, please explain.

CONFIDENTIALITY
In order to serve clients effectively, all volunteers of Jewish Federation and Family Services of Orange County must maintain strict confidentiality with respect to all information about clients including names, addresses, and phone numbers.  Please do not discuss any information about a client except with appropriate personnel within the agency.  Breach of confidentiality is a violation of the law which can lead to civil liability and a fine.  It is also a violation of ethical conduct.

If in the course of your work you suspect a case of child or elder abuse/neglect, please report this to the Program Coordinator.  Counselors, professional staff and volunteers are mandated to report on such cases to the proper authorities.

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* Digital Signature
By entering your full name, you certify that the statements made in this Volunteer Application are true and correct and have been given voluntarily. I further certify that I have read and understand the legal disclosure and confidentiality statement above.

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