Senior Volunteer Application – Hearts with a Mission

Hearts For Seniors Volunteer Application

Step 1 of 5

Contact Information
Legal Name (as on Passport)*
First Last
Preferred Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Work Phone
Date of Birth*
MM slash DD slash YYYY
Gender
Email*
Background
Have you ever been charged with or convicted of any crime, including a felony or misdemeanor?*
- Yes
- No
Please describe when, where and the nature of the charge(s).*

Referral
How did you hear about Hearts With A Mission?

Special Skills or Qualifications*
Summarize your special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports, and how you think you can help Hearts For Seniors.
Affiliations*
Summarize your past or present church, civic or auxiliary affiliations, interests, or experience that may be helpful as a volunteer.
1st Personal References*
Name Phone Number
2nd Personal References*
Name Phone Number
3rd Personal References*
Name Phone Number

Volunteer Questionnaire
Please answer the following questions, citing personal experiences that relate to your answers.
In some cases, team members may voluntarily assemble for prayer and devotions. Please explain your opinions and/or feelings on this matter.*
What church are you affiliated with, if any?*

Background Check
(The background form will be sent later)
I certify that all statements made in my application and all descriptions of my work history are true, accurate and complete. I hereby expressly authorize Hearts With A Mission, its officers, agents and employees, to investigate in any manner they deem appropriate, at their sole discretion, my medical, health, educational, employment, community service or professional background, public or private records including but not limited to law enforcement and court records and personal references. I further consent to and authorize Hearts With A Mission to communicate with any and all of my previous or current employers relating to my work record and experience.

In consideration of being evaluated for volunteer service with Hearts With A Mission, I hereby release and forever discharge Hearts With A Mission, its officers, agents and employees from any and all claims, demands, damages or liability relating to or arising out of the requesting of, or furnishing of, any information relating to my medical, health, educational, employment, community service or professional background, and public or private records including but not limited to law enforcement and court records and personal references as described above.

I agree that Hearts With A Mission may use my name, any photographs and video of me for publicity or promotion purposes without liability or obligation to me.
Hearts With A Mission General Release
In consideration of Hearts With A Mission (HWAM) arranging a volunteer assignment for me, and with the intention of binding myself, my heirs, legal representatives, successors and assigns, I hereby expressly RELEASE AND FOREVER DISCHARGE Hearts With A Mission, its officers, directors, employees, volunteers, agents, legal representatives, insurers, successors, and assigns from any and all claims, demands, damages, liabilities, and causes of action that I now have or may in the future have, whether known or unknown, of whatsoever nature, relating to or arising out of my selection as a volunteer by, or my service as a volunteer with, Hearts With A Mission whether or not due to Hearts With A Mission’s negligence, strict liability, or any other breach or fault. This includes, but is expressly not limited to, death, bodily injury, personal injury, property damage, loss or theft of property, economic loss, or any other damage, loss, or cost.

This document shall be construed according to the laws of the state of Oregon. If a dispute should arise with respect to the meaning of any of the terms of this document, the rule of construction that a document is construed against the party preparing such document shall specifically not be applicable to the interpretation of this document.

This General Release represents the entire agreement of the parties hereto and supersedes any and all prior or contemporaneous oral or written understandings, statements, representations, or promises. All of the terms hereof are contractual and not mere recitals.

I acknowledge that I have carefully read this General Release, know and understand the contents thereof, and that this document was freely and voluntarily executed. I acknowledge that I was given the opportunity to seek independent legal counsel on any and all matters herein before I signed this General Release.
I Accept*
I Accept the Hearts With A Mission General Release
Your Name*

Your typed name acts as your signature on this volunteer application.
Date*
MM slash DD slash YYYY
Number
Number

Hearts For Seniors Volunteer Application

Step 1 of 5

Contact Information

Background

Referral

Volunteer Questionnaire

Background Check

Hearts With A Mission General Release

Contact HWAM

Locations

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