Row rect Shape Decorative svg added to bottom Volunteer Application Volunteer Application Name First Last Under 18? Yes No Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneEmail Emergency Contact NameRelationshipEmergency Contact Phone 1Emergency Contact Phone 2Have you ever been convicted of a criminal offense? Yes No If yes, please explain:Have you been convicted of a crime that is a misdemeanor or felony in the past 10 years? Yes No If yes, please explain:References (Please do not list relatives)NameRelationshipPhoneNameRelationshipPhoneEAAA Employees You KnowConfidentiality Statement*I understand that in the performance of my duties on behalf of Eastern Area Agency on Aging, I will have access to sensitive information about the client I am serving, and that such information may include medical, insurance, financial, and other sensitive and confidential personal information. I agree to restrict my use of such information to the performance of my duties as a volunteer of Eastern Area Agency on Aging. I agree I will not discuss cases or mention client(s’) names, or otherwise reveal or disclose information pertaining to any client, except within department rules and regulations. Information will only be released to or shared with Agency on Aging staff, and/or those persons/agencies/businesses that the client (or his/her legal representative) has expressly given permission to do so – and then only for the purpose of assisting the client. I also agree that I will provide my full name, position with the agency and the purpose of obtaining the information on behalf of my client. I hereby acknowledge my obligation to respect the client’s privacy and the confidentiality of the information pertaining to the client, and to exercise good faith and integrity in all dealings with the client and his or her personal information in the performance of my duties as an employee of Eastern Area Agency on Aging. I also understand that any unauthorized use or disclosure of information about or pertaining to a client may result in disciplinary action by Eastern Area Agency on Aging, and may subject me to civil liability for breaching the client’s right to privacy. I also understand that any willful and knowing false representation, for the purpose of obtaining information from those agencies and businesses whose records are subject to the Privacy Act, may be criminally prosecuted. I Agree Release and Waiver*I, the volunteer, do release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. As it is not required to provide insurance by law, I understand that Eastern Area Agency on Aging does not provide Workers’ Compensation Insurance coverage for volunteers, including someone under 18. I Agree Public Media Release Statement*I do hereby irrevocably grant permission to Eastern Area Agency on Aging (EAAA), its employees, agents, representatives, successors, assigns, and affiliates, to take photographs, recordings, and other digital images. I understand that EAAA will use or publish the photographs, recordings and other digital images in print or electronic promotional, informational, or educational materials, including without limitation use on advertisements, video communication, websites, blogs, electronic mailings and presentations, newsletters, news releases, and/or other print or electronic communication. I understand EAAA may also share with other community partners, foundations and businesses these photographs, recordings or digital images to use as they deem necessary. I understand and agree the use of such photographs, digital images and recordings are at the discretion of EAAA and I will have no control over the design, layout, editing, alteration, and use of the same. I authorize the aforementioned use of these photographs, recordings and other digital images without compensation to me (or my minor children, if applicable). All negatives, prints, digital reproductions, and other recorded images shall be exclusively the copyright/property of EAAA. I agree Volunteer Opportunities Nutrition: Meals on Wheels driver, community café assistants, kitchen assistance, Community café, Furry Friends (distributing pet food) and Commodities (distributing 30 lb. boxes of federal food) Senior Medicare Patrol & State Health Insurance Assistance Program (SHIP): Helping people to understand Medicare & other insurance options Money Minders Helping people to balance their checkbook, create budgets and pay bills Wellness: Help with education, movement and balance classes Durgin Center: Help with activities, social engagement, and administrative tasks Other opportunities: Clerical, Board, Grant research, much more…contact us with other volunteer interests @ 1-800-432-7812 To help us assign you to a position that you will most enjoy, please look over the following choices below and select those that would interest you.Do you have any restrictions for volunteering? (For example: non-driver, lifting, hours available)Authorization to Release Information to Eastern Area Agency on Aging*I hereby authorize the Eastern Area Agency on Aging to perform a license check with the Motor Vehicle Division of the State of Maine and a background check with the Department of Public Safety, State Bureau of Identification, Federal background check, National Sex Offender Registry Check and Office of Inspector General and US Dept of Health and Human Services Fraud Prevention Check. I hereby release all individuals connected therewith from all liability for any damage what so ever incurred in furnishing such information. I understand that this information is being released in confidence and will be kept confidential by Eastern Area Agency on Aging. By signing this release I authorize Eastern Area Agency on Aging to complete a background check as required by state and federal guidelines. I also understand that I must update Eastern Area Agency on Aging staff with any new information listed below should that change at any point during my tenure with the agency. I Agree Date of Birth* MM slash DD slash YYYY Required for Background CheckDrivers License Number*Required for background checkMaiden Name or any other prior name(s) used (enter n/a if not applicable)*Required for background checkSocial Security NumberFor Background checkCAPTCHA
