Volunteer Application - Adult Personal Information Name * First Last * LastAddress Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Work Phone Cell Phone Email * Date of Birth In case of emergency, please notify Relationship Phone Are You Retired? Yes No If no, where are you employed? What is/was your occupation? How did you find out about JGS volunteer opportunities? Why do you want to volunteer? Community affiliations or club/organizational memberships: Please list any prior/current volunteer work experience: Special skills, interests, hobbies, languages, talents (music/dance/art) you would like to share with resident: Do you smoke (use tobacco products or E-Cigarettes)? Yes NoJGS Lifecare is a “smoke-free” campus and no longer hires employees or volunteers who smoke. When can you begin volunteering? How often would you want to volunteer? 1x per week 2x per week 1x per month Days available Monday Tuesday Wednesday Thursday Friday Saturday SundayTimes available Mornings Afternoons Evenings WeekendsPlease check off any of the areas below that interest you.(Jewish Nursing Home = JNH; Ruth’s House Assisted Living = RH; Adult Day Health = WADH)Interests Recreation Activities Assistance (JNH/RH)Bingo, Arts &Crafts, Spelling Bee, Board GamesDiscussion GroupsComputer classMusic programsBridge/Mah JongDay Trips Coffee Shop (JNH) Religious Services (JNH) (Fri. 3:30 PM/Sat. 9 AM) Adult Day Care Assist (WADH) Caring Friend (JNH/RH) Library Cart (JNH/RH) Administrative Assistance (JNH/RH) Transporting Residents w/i JNH/RH Monthly Birthday Parties (JNH) Monthly Summer Picnics (JNH) Cafeteria Assistance – Cashier (JNH) Gift Shop (JNH) Please describe any physical or mental conditions or restrictions you have that might affect your ability to perform certain activities Physician’s Name Physician's Phone Personal References(preferably not a relative or spouse) Reference 1 Name Reference 1 Phone Reference 2 Name Reference 2 Phone JGS Lifecare, Corp. has my permission to contact references.Signature * By checking this box, I confirm that this checkbox serves as my electronic signature. Captcha If you are human, leave this field blank. Submit