Ombudsman Volunteer Application - Kern Long Term Care

Personal Information

First Name*

Middle Initial

Last Name*

Current Address

City

State

Zip Code

Primary Phone*

Email Address*

Qualifications

Are you at least 18 years of age?*

Yes
No

How many hours are you available to volunteer?

(15hrs minimum)

Please enter a number greater than or equal to 15.

Are you willing and able to make a one-year minimum commitment to volunteer with the LTC Ombudsman Program?*

Yes
No

Do you have reliable transportation?*

Note: If you will drive your own vehicle for Ombudsman program activities, you will need to show proof of automobile insurance.

Yes
No

Please explain what skills, abilities, and experience you would bring to the volunteer position

Are you fluent in any languages other than English?*

Yes
No

If Yes, What language(s)

Volunteer Experience

Please describe any volunteer experience you have including name of the organization and the duties you performed

Work Experience

First Employer's Name

Position Held with First Employer

Dates Employed by First Employer

Second Employer's Name

Position Held with Second Employer

Dates Employed by Second Employer

Education

First Institution's Name

First Institution's City

First Institution's State

Certificate, degree, and/or area of study with First Institution

Second Institution's Name

Second Institution's City

Second Institution's State

Certificate, degree, and/or area of study with Second Institution

Conflict of Interest

Do you have a competing interest, obligation, or duty that comprises, influences, or interferes with your objectivity or capacity to fulfill your duties as a LTC Ombudsman?*

Yes
No

If Yes, please explain

Do you own, or are you currently employed by a nursing facility or a residential care facility?*

Yes
No

If Yes, where are you employed?

Have you been employed by a nursing or residential care facility in the past?*

Yes
No

If Yes, when and where were you employed

Are you related to anyone (directly or by marriage) who owns or is employed by any of the above named types of long-term care facilities?*

Yes
No

Background Information

Have you ever been arrested, charged, convicted, or pled nolo contendere or guilty, or entry into a diversion program for any violation of federal or state law?*

Yes
No

Note: Answering Yes to this question will not automatically make you ineligible to be an ombudsman.

If Yes, describe the date(s) and offense(s)

As this volunteer position regularly requires working with vulnerable adults, we will need to complete a criminal background check & Live Scan on each applicant. Will you grant permission for this to be done?*

Yes
No

Please note that a criminal background check will be conducted as part of the volunteer application and screening process. Note: Failure to disclose record(s) of a criminal conviction will result in an automatic disqualification. All information obtained during the screening process will be kept confidential.

References

Please list two individuals who know you well to act as personal/professional references. Please do not list relatives.

First Reference's Name

Relationship with First Reference

First Reference's Phone

First Reference's Email

First Reference's Address

First Reference's City

First Reference's State

First Reference's Zip Code

Second Reference's Name

Relationship with Second Reference

Second Reference's Phone

Second Reference's Email

Second Reference's Address

Second Reference's City

Second Reference's State

Second Reference's Zip Code

Application Agreement*

I certify that all information is true, complete, and has been given voluntarily. I have read the minimum requirements (online) and understand the commitment. I hereby authorize the Kern County Long-Term Care Ombudsman Program to make whatever inquiries are necessary to verify any of the above facts. I understand that any information obtained during the screening process will be kept confidential.

Date*

Applicant's Signature*

Icon in bottom right corner will reset/erase signature

Comments

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