4847 Fred Gladstone Drive
West Palm Beach, FL 33417
Phone: (561) 561-341-8895 E-mail:
[email protected] STUDENT MENTORING - VOLUNTEER APPLICATION
First Name ____________________________ Last Name ________________________________
Address ____________________________________________________Apt. # ________________
City _____________________________________State_______________ Zip ________________
Cell Phone________________________________
E-mail Address _______________________________ Date of Birth _________________________
Parents/Guardian Information
Mother/Guardian Name _______________________ Father/Guardian Name________________
Home Phone_________________________________ Home Phone_______________________
Work Phone__________________________________ Work Phone_______________________
Cell Phone___________________________________ Cell Phone_________________________
Name of school currently attending________________________________ Grade Level__________
The career track program you are enrolled in__________________ Instructors Name____________
In case of emergency please notify ____________________________________________________
Relationship __________________Phone _______________________Cell____________________
List community affiliations, or school clubs/organizations that you are a member________________
________________________________________________________________________________
Please list any prior volunteer work experience __________________________________________
How did you find out about our volunteer opportunities? ___________________________________
If your family member works on the Campus, please complete the following:
Name____________________Department/Position__________Relationship to you______________
Areas of Interest
___Administrative Help
___Resident Socialization ___Activity Leader Filing, scanning,
Long Term Cards/games shredding, data entry
Assisted Living Book group
Memory Care Craft ___ Escorting/Transporting
PACE Center Discussion group-topic to Residents to on campus
be agreed upon ahead of appointments
___Activities Assistance time.
Other: ___Long Term Care floor
Arts & Craft
Food tray delivery/pick up
Music Sharing Hall monitor-checks in on
residents
List special skills or hobbies__________________________________________________________
How often would you want to volunteer? ___1x per week ___2x per week ___3x per week
Days and times available (please check all that apply)
_________Mon. _________Tues. _________Wed. _________Thurs. _________ Fri.
_________Sat. _________Sun. What Hours ________________________________
Do you have any medical conditions or restrictions you have, that might affect your ability to perform
certain activities Yes No
PERSONAL REFERENCES (cannot be a family member or relative)
1. Name ____________________________ Phone #: _____________________ Email_________________________
2. Name _____________________________Phone #: _____________________Email_________________________
MorseLife has my permission to contact my child’s references. My signature below authorizes my child to volunteer at
MorseLife and commits my son/daughter to upholding the center’s rules of confidentiality and residents’ rights.
Signature of Applicant ________________________________________ Date ____________________________
Signature of guardian if applicant is under 18 years of age __________________________________________________
Relationship to applicant ______________________________________ Date ____________________________
FOR AGENCY USE ONLY
Interviewer____________________________ Date ________________ Approved __________________
Comments ________________________________________________________________________________________________________________
Date Entered in Salesforce: ______________ Assignment: ___________________________________________________ Start Date:_______________________________
