Volunteer Application/Ombudsman Program

Long-Term Care Ombudsman Program

Volunteer Ombudsman Application Form

"*" indicates required fields

Step 1 of 3

Date*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Please reenter your email to verify*

Phone*

Previous Work Experience*

Are you or have you ever been employed by a Long-Term Care Home?*

Yes

If yes, please specify home and year(s) of employment:*

If No, please enter N/A

Have you had previous volunteer experience? Please name program/organization and duties:*

If No, please enter N/A

Special Skills or Interests: (ie: clerical, telephone, organizing, marketing, foreign languages, counseling, nursing, etc...)*

Why do you want to be a Volunteer Ombudsman?*

Are you willing to devote 4 hours per week to the Volunteer Ombudsman Program plus the time needed to follow through on critical issues?*

Yes

This position requires some physical activity: stairs, driveways, long corridors, and standing. Is this something you feel comfortable doing?*

Yes

What is the best time of day to contact you?

Please submit three professional references work, school, volunteering, community --- please, no family members

Reference 1*

First Last

Phone*

Reference 2*

First Last

Phone*

Reference 3*

First Last

Phone*