Name
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First Name
Last Name
Birthdate
*
MM
DD
YYYY
Email
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about NewBridge?
*
Occupation
*
Emergency contact name
Emergency contact phone number
*
(###)
###
####
Personal or professional reference
*
Email of reference
*
Phone number of reference
*
(###)
###
####
Personal or professional reference
Email of reference 2
Phone number of reference 2
(###)
###
####
Volunteer opportunity you are applying for
*
Please select 1 or 2 that you are most interested in.
Why are you chosing to apply for this opportunity vs some of our others?
*
What area of Madison would you prefer to volunteer in?
We try our best to match volunteers with programs and areas that are most convenient for them. However, the needs of the people we serve doesn't always make that possible.
Previous volunteer experience
I've received the vaccine for COVID-19
*
Have you ever been convicted of, or do you presently have pending, any violations of law?
*
If you answered yes to the above question please explain below.
To ensure quality service and protect the older adults we serve NewBridge will check applicant references and check records for criminal history (via Wisconsin Criminal History Record Check website, https://recordcheck.doj.wi.gov). I authorize the staff of NewBridge to contact the above references and check with the appropriate authorities on matters of public record regarding my background, as related to this volunteer position. I understand this information will be kept confidential. I give my permission to NewBridge to conduct a background check on me. I understand that the results could disqualify me from providing service. By entering your name below you give NewBridge consent to complete these checks prior to your placement. (under 18 have parent put name)
*
Gender
*
Race
*
Do you have a disability?
*
Photo Release
*
I understand photographs are taken of NewBridge staff, senior adult participants, and volunteers. I also understand and agree that these photos may be used for brochures, newspapers, newsletters, power point presentations, the agency website and posters in marketing NewBridge.
Confidentiality Policy
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All staff and volunteers of NewBridge (NB) will maintain confidentiality with regard to participant information and records. Any information relating to individuals attending programs or activities at NB that would be detrimental to their character or well-being is not to be discussed in any manner outside of communicating with staff and/or volunteers in the ongoing work.
Staff and volunteers are exposed daily to a great deal of confidential information. None of this information including the method or procedure used for handling a specific case should be repeated or discussed with relatives, friends, or anyone outside NB. Confidential information should only be discussed with staff and volunteers when necessary to the process of daily business. All personnel information is confidential.
The names of senior adults receiving services at NB will at all times remain confidential. Names will not be disclosed to any unauthorized person, or agency, without written consent of the senior adult or their guardian.
NB’s contract with Dane County states all staff and volunteers understand improper disclosure of information about people served by NB may subject them to legal sanction or fine.
Waiver and Release of Liability
*
I understand that NB is not responsible for any lost, stolen, or damaged valuables while I am engaged in volunteer activities. I certify that I am physically fit to participate in volunteer activities. I understand and agree that when volunteering for NB I will not participate in the following activities: move furniture or equipment, drive clients, handle money or personal documents, use a ladder/stool to complete tasks, use equipment that I do not deem safe or suitable.
Insurance
*
I understand I am not covered under hire/non-owned auto coverage and under general liability. While volunteering for the Home Chore program, the agency does not cover auto insurance while you are driving you own vehicle. In the course of your duties, you do not have coverage for incidence that occurs in the senior’s home. It is your duty to inform your personal and auto carriers to get additional coverage.
