VOLUNTEER APPLICATION
Please send completed application to:
Full Life Care, Volunteer Coordinator
800 Jefferson Street, Suite 620
Seattle, WA 98104
OR Fax: 206-224-3779
Questions? Please call
(206) 224-3790
NAME________________________________________________
DATE_________________________________
ADDRESS_____________________________________________
BIRTHDATE___________________________
CITY_______________________ STATE_______ZIP__________
EMAIL________________________________
HOME PHONE___________________ WORK PHONE____________________ CELL _____________________
OCCUPATION OR AREA OF STUDY ______________________________________________________________
ARE YOU A MILITARY VETERAN?___________YES____________NO
Why do you wish to volunteer at Full Life Care?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
What previous volunteer experiences have you had?
________________________________________________________________________________
________________________________________________________________________________
What experiences have you had in working with elderly persons with disabilities or people in vulnerable
situations? _______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Do you have any special training or certifications? _________________________________________
________________________________________________________________________________
________________________________________________________________________________
Do you have any history of sexual or violent offense against others? ____YES ____NO
Office Use:
Orientation ________________
WSP Date ________________
WSP Notice________________
Data Entry_______________
TB_____________________
Food Handler’s ___________
Ref1_______________
Ref2_______________
1mo_______________
3mo_____________
add’l____________
exit_____________
Any language fluency other than English? ____________________________________________
What hobbies or skills you are willing to share? ________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
How much time would you like to volunteer? Hours/week_______
hours/month______
Days/ times available:
Mon
Tues
Wed
Thurs Fri
Sat
Sun
Mornings
      

Afternoons
      

Do you prefer to work: directly with participants
 indirectly with participants 


If you have any disability that requires accommodations in order to perform this volunteer position,
please inform us as to how we can be of assistance: ____________________________________
____________________________________________________________________________
List two references that are not related to you: (preferably one who has supervised you):
Name _____________________ Relationship ________________ Phone or Email______________
Name _____________________ Relationship ________________ Phone or Email______________
In case of emergency please contact:
Name _____________________ Relationship ________________ Day Phone _______________
Physician’s Name ________________________________ Phone _________________________
Medical Plan_________________________ Hospital of choice_________________________
Consent to Medical Care: “I hereby authorize Full Life Care to seek medical attention in case of emergency.”
Signature of Volunteer____________________________________________
(Parent of Guardian signature needed if under 18 years of age)
I certify that the information on this application is true and complete to the best of my knowledge. I understand
that this information is confidential within Full Life Care.
________________________________________
_________________________
Signature
Date
Volunteer Activity Interest Sheet
Your Name:_________________
Date:_______________________
Working directly with clients
1.
Working indirectly/ behind the scenes
3.
o Greeting
o Serving Coffee/Tea
4.
o Speaking/presentation on behalf of Full
Life Care *
o Event assistance
o Reading the paper
o Event coordination
o Playing card games
o Outreach/PR
o Assist with activities
o Arts and crafts
5.
o Volunteer recruiting
o Data entry
o Word games
o Make phone calls
o Music
o Filing
o Computer tutor
o Provide entertainment
6.
o Cleaning/maintenance
o Share travel slides
o Yard or garden work
o Physical games*
o Handy-person/small repairs
o Dance/movement*
o Nail Care*
7.
o Push wheelchairs*
o Walk with clients*
2.
o Feed clients*
o Lead activity groups*
o Sewing/mending
o Help with fundraising
o Exercise*
o Serve lunch*
o Shredding
8.
o Collect donated items
o Make decorations
What other skills would you like to share?
____________________________
____________________________
_______________________________
_________________________
* indicates specific training provided with staff
approval
Criminal History Disclosure
Applicant Name:
Date:________________
Policy:
All prospective Full Life Care employees and volunteers will be subject to a criminal history
background check. Full Life Care will not hire persons who have committed crimes against children or
vulnerable adults. As part of the application process, you are required to disclose criminal history in
writing. Please answer the following questions by checking “yes” or “no.”
Have you ever:
Yes
No
been convicted of any crime against children or other persons?
Yes
No
been convicted of crimes relating to financial exploitation if the victim was a
vulnerable adult?
Yes
No
been convicted of crimes related to drugs as defined in RCW 43.43.830?
Yes
No
been found in any dependency action under RCW 13.34.040 to have sexually
assaulted or exploited any minor or to have physically abused any minor?
Yes
No
been found by a court in a domestic relations proceeding under Title 26 RCW to have
sexually abused or exploited any minor or to have physically abused any minor?
Yes
No
been found in any disciplinary board final decision to have sexually or physically
abused or exploited any minor or developmentally disabled person or to have
abused or financially exploited any vulnerable adult?
Yes
No
been found by a court in a protection proceeding under chapter 74.34 RCW, to have
abused or financially exploited a vulnerable adult?
___________________________________________________________________________________
Washington State Patrol and/or Department of Social and Health Services(DSHS) background check
Please provide as much information as possible. Name and date of birth are mandatory.
Applicant's Name:_____________________________________________________________________________________________________________
Last
First
Middle
Alias/Maiden Name(s):_________________________________________________________________________________________________________
Date of Birth:_________________________________
Sex:_______________
Race:___________________
Month/Day/Year
By signing this document, I swear, under penalty of perjury, that I have truthfully disclosed all information
pertaining to criminal history. I give Full Life Care permission to perform a background check as required by
the Child/Adult Abuse Information Act RCW 43.43.830 through 43.43.845.
Signature
Date