Form Center

2. Lumpkin County Senior Center Volunteer Application
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Home Phone
14. Cell Phone
16. Best Time to Call
17. Birth Date
19. Education and training background:
21. Previous or Present Volunteer Jobs:
23. Special skills, training and interests/hobbies:
25. Do you have any health limitations or restrictions to perform any duties?

    1. No
    2. Yes
26. If yes, what limitations?
28. Days Available

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
32. Personal References
    Please list the names of three (3) individuals we may contact as a reference. Do not list relatives.
34. Reference 1
36. First Name
37. Last Name
39. Phone Number
40. Relationship
42. Email Address
44. Reference 2
46. First Name
47. Last Name
49. Phone Number
50. Relationship
52. Email Address
54. Reference 3
56. First Name
57. Last Name
59. Phone Number
60. Relationship
62. Email Address
66. Emergency Contact
68. First Name
69. Last Name
71. Phone Number
72. Relationship
76. Background Information
    A background investigation and fingerprinting will be required BEFORE placement in any sensitive volunteer position.
78. Confidentiality
    Volunteers are responsible for maintaining the confidentially of all proprietary or privileged information to which they are exposed while serving as a volunteer, whether this information concerns overall Senior Center business or involves an individual staff member, volunteer, participant, or another person.
80. Conflict of Interest
    Lumpkin County Senior Center volunteers are not allowed to promote any for-profit business or solicit center participants for services or personal gain, hand out business cards, or collect contact information from participants for personal or professional use. Volunteers should not enter into any relationships with center participants through which they earn a fee or commission.
82. Volunteer Responsibility
    I understand that, as a volunteer, I have the responsibility to conduct myself professionally and protect and preserve the privacy and confidentiality of all participants at the Lumpkin County Senior Center.
84. Authorization
    I authorize investigation of all statements contained in this application and any supporting documents and I understand that a background check may be conducted. I authorize Lumpkin County to secure information from the references I have provided and release all parties from any liability arising from such investigation.
86. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) you are agreeing to the statements above regarding background, confidentiality, conflict of interest and volunteer responsibility.

    1. I agree.
88. Electronic Signature
89. Date
    Date
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit

* indicates a required field