Name:

Address:

City:

State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

H Phone: W Phone: Fax:

Email:

Birthday (mm/dd):

1.

Please check the volunteer position you are seeking.

2.

Why do you want to become a volunteer for the Long-Term Care Ombudsman (LTCO) Program?

3.

What do you hope to accomplish as a volunteer with the LTCO Program?

4.

How did you first learn about volunteering with the LTCO Program?

5.

How many hours a month would you be available to volunteer with the Ombudsman program?

hrs/month

6.

Are you currently employed?

Yes No

7.

Briefly describe previous related experience(s) to this volunteer position:

8.

Have you ever been inside a nursing home?

Yes No

9.

Are you a provider of any services that are monitored by the California Long-Term Care Ombudsman Program? (i.e., Do you own or are you employed by a nursing facility or a residential care facility?)

Yes No

10.

Have you been employed by a skilled nursing or residential care facility in the past?

Yes No

If your answer was yes, when and where were you employed?

11.

Are you related directly or by marriage to anyone who owns or is employed by a skilled nursing facility or a residential care facility?

Yes No

12.

Do you presently work as a volunteer in a skilled nursing facility or a residential care facility?

Yes No

13.

Is there any other issue that might constitute a potential conflict of interest for you as an Ombudsman?

14.

Please check your level of education:

15.

Please check below all the special skills or interests that you have:

16.

Are you willing and able to make a one-year commitment to volunteer with the Ombudsman Program?

Yes No Unsure

17.

Do you have any questions or concerns about the volunteer position?

18.

List any previous volunteer experience(s) that you have had. Please include the organization, your involvement, and the length of time you volunteered:

19.

Please supply any other information you that feel/think might be valuable:

20.

As this volunteer position regularly requires working with vulnerable adults, we will need to do a criminal background check. Do you grant permission for this to be done?

Yes No

21.

Do you have a valid California Driver's License?

Yes No

If yes, please provide the number :

and expiration date:

To become a Certified Ombudsman, training is required by the Office of the State Long-Term Care Ombudsman and the California Department of Aging. You are required to take at least 36 hours of training that will be provided by the program.

Please list three references we may contact. These should not be relatives:

Reference 1

Name:

Address:

City:

State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

H Phone:

W Phone:

Reference 2

Name:

Address:

City:

State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

H Phone:

W Phone:

Reference 3

Name:

Address:

City:

State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

H Phone:

W Phone:

Submit Volunteer Application :