ӣ��Ƶ Long-Term Care Ombudsman

NEW! Medicaid Cuts: A Message from Nursing Home Residents

NEW VIDEO! Consumer Voice 2024 Residents' Voice Challenge:

Volunteer Advocate Program Online Application

Please supply the requested information below. If you would rather fill out the application and mail it to us, please use the printable application.

First Name

Last Name

Preferred Gender Pronoun

Address Line 1:

Address Line 2:

City:

County:

State:

Zip

Your Home Phone Number: (Enter Numbers Only)

Your Cell Phone Number: (Enter Numbers Only)

Are You Vaccinated For Covid-19

Your E-mail Address:

How did you learn about the Volunteer Advocacy Program?

Have You Ever Visited A Relative/Friend In A Nursing Home?

Please Describe Your Experiences:

What days and times are most convenient for you to volunteer

Do you have transportation to take you to the assigned facility weekly?

Will you be able to spend an average of four hours weekly?

Are you willing to keep records and complete reports?

Volunteer Experience
Have you ever been a volunteer before? If so please list previous experiences:

Start Date

End Date:

Name of Organization:

Type of Organization:

Duties:

Start Date

End Date:

Name of Organization:

Type of Organization:

Duties:

Employment History
Please list previous work experience if applicable:

Start Date

End Date:

Employer:

Type of Business:

Duties:

Start Date

End Date:

Employer:

Type of Business:

Duties:

Have you ever worked in a Long-Term care facility before?

Where:

In what capacity:

Education:

High School

College:

Major Area of Study:

Degree:

Other Studies:

Any additional information you feel may be useful:

Please supply three references we may contact (No relatives)

Reference #1

Name:

Address:

City:

State:

Zip:

Phone Number: (Enter Numbers Only)

Email Address:

Reference #2

Name:

Address:

City:

State:

Zip:

Phone Number: (Enter Numbers Only)

Email Address:

Reference #3

Name:

Address:

City:

State:

Zip:

Phone Number: (Enter Numbers Only)

Email Address:

I acknowledge that I have read and understand the Volunteer Advocate Program job description and am capable of performing all of the stated requirements.

I acknowledge that I have read and understand the Consent to Criminal Background Check document and agree to the terms and conditions outlined.

I acknowledge that I have read and understand the Individual Conflict of Interest document and agree to the terms and conditions outlined.

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Last Updated: Friday, 05/09/25

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Volunteer Advocate Program Online Application

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