Fillable HEALTH AND HUMAN SERVICES VOLUNTEER APPLICATION (Waukesha County Government)

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HEALTH AND HUMAN SERVICES VOLUNTEER APPLICATION (Waukesha County Government)

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HEALTH AND HUMAN SERVICES VOLUNTEER APPLICATION
Aging and Disability Resource Center (ADRC)
Health and Human Services (HHS)
(262) 548-7848 (262) 548-7284
Please Print
Personal
Name/Last ___________________________ First ___________________ Middle _______________________
Address ___________________________________________________________________________________
City _________________________________________________________ Zip __________________________
Home Phone (____)_____________ Work Phone (____)_____________ Cell Phone (____) _________________
____ Male ____Female DOB _____/_____/_____ Email ________________________________
Preferred method of contact: Phone Email
Volunteer position applying for ________________________________________________________________
How did you hear about us? __________________________________________________________________
Volunteer Experience
Agency __________________________ Address __________________________ Phone (____) ____________
Position ___________________ Supervisor ____________________ May we contact agency? ___ Yes ___ No
Agency __________________________ Address __________________________ Phone (____) ____________
Position ___________________ Supervisor ____________________ May we contact agency? ___ Yes ___ No
Employment History
Name of current employer ___________________________________ Phone (____) _____________________
Address _______________________________________ Dates employed – from _______ to ______________
Name of supervisor ______________________________ Job title ____________________________________
May we contact employer? ___ Yes ___ No Description of duties ______________________________
Education/Background
Please list education, skills, interests, and hobbies: ________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
References
Name ________________________________ Relationship ______________ Phone (____) ________________
Address ___________________________________________________________________________________
Name ________________________________ Relationship ______________ Phone (____) ________________
Address ___________________________________________________________________________________
In Case of Emergency, Please Notify
Name _____________________________ Relationship ______________Day Phone (____) _ _______________
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Waukesha County acknowledges that equal opportunity for all persons is a fundamental human value. Each volunteer applicant
will be considered on the basis of individual ability and merit, without regard to race, color, age, religion, national origin,
disability, sexual orientation, sex, or marital status.
HHS-1070; 01/14, Rev. 05/19
Driving Information
If you are volunteering for a position that requires driving, Waukesha County policy requires a valid Wisconsin driver’s
license and proof of automobile insurance. Are you able to use your automobile if the volunteer position requires one?
____ Yes ____ No
As a volunteer, I agree to provide a valid Wisconsin driver’s license number and proof of automobile insurance. I
agree to mail or deliver copies of these documents to HHS so that they can be filed with this application.
Automobile insurance company ___________________________________ Policy number _______________________
Driver’s license number _________________________________________
Waukesha County policy states ‘acceptable driving records include those with no (0) Operating Under the Influence
(OWI)/Driving Under the Influence (DUI) charges within the last three (3) years and a maximum of one (1) at-fault
accident and up to two (2) moving violations in the past three (3) years.
Criminal History
Have you ever been convicted of a misdemeanor or felony or are any misdemeanor or felony charges pending against
you? If yes, please explain. (Note: Answering yes will not automatically prohibit individuals from becoming volunteers,
but will be considered with respect to time, circumstances, seriousness and relationship to volunteer responsibilities.) _
Yes No ___________________________________________________________________________________
_________________________________________________________________________________________________
Acknowledgement of Confidentiality / Consent / Vehicle Use Agreement
Acknowledgement of Confidentiality: As a volunteer, I agree that matters pertaining to clients of HHS are confidential.
I agree that I will not discuss or disclose any of client information with anyone outside of HHS at any time. I also
understand that as a volunteer, I am considered to be a valuable member of the HHS workforce and will be required to
participate in Initial and Annual HIPAA (Health Insurance Portability and Accountability Act) Awareness training.
Conse nt: My signature below certifies that all statements made on this application are true, complete and correct to
the best of my knowledge and belief. I understand these statements are subject to verification. I understand that
falsification on this application can disqualify me from consideration or result in my volunteer services being denied.
Furthermore, my signature below provides my authorization to Waukesha County to conduct driver license, motor
vehicle record, and criminal background checks, as needed, as well as reference checks to determine my suitability for
placement. I hereby release all parties from any liability for furnishing this information.
Vehicle Use Agreement: If operating a personal vehicle for County business, I currently possess a valid Wisconsin
driver’s license or commercial driver’s license and will immediately notify my volunteer supervisor if my driver’s license
is restricted, suspended, revoked, or expired. I will maintain automobile liability insurance coverage on the motor
vehicle.
Signature of Volunteer ______________________________________________ Date __________________
Print name of Volunteer ___________________________________________________________________
Parent Consent
The following must be completed if applicant is under 18 years of age.
I give my consent for my child, named on page one of this application, to provide volunteer services to Waukesha County. I also give
Waukesha County my consent to obtain any emergency medical treatment necessary for the safety of my child.
Signature of Parent/Guardian_________________________________________ Date _______________________________________
EXCLUSIVE FOR AGING & DISABILITY RESOURCE CENTER
SENIOR DINING SITES - Volunteers must be 18 years of age. Aging & Disability Resource Center Volunteers age 14-17
are allowed, but must be accompanied by a parent or responsible adult at all times.
HOME DELIVERED MEAL DRIVERS – The ADRC does not encourage volunteers accompanied by minor children, but will
not prohibit the practice if the child in the company of the volunteer is over the age of six. Volunteers accompanied by
a child while performing volunteer work do so at their own risk and assume any liability for injury to the child.
Will you have someone riding with you in the car?
____ Yes ____ No If child, provide age _______
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HEALTH AND HUMAN SERVICES VOLUNTEER APPLICATION (Waukesha County Government)

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Completed 18 July 2020

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