Volunteer Application - Youth 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 If under age 14, name of adult who will accompany you? (otherwise, JGS Lifecare will assign adult to accompany you) In case of emergency, please notify Relationship Phone Name of School/College/University currently attending What is your current grade? How did you find out about JGS volunteer opportunities? Why do you want to volunteer? Is your volunteering part of a community service requirement? Yes No If yes, from what organization/school? (Please provide required authorization form) Date received 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(Teacher, Employer, Administrator, Family Friend) 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