Volunteer Application Apply to be a volunteer Long Term Care Ombudsman TitleMr.Mrs.Ms.Name* First Last Date of birth* Contact Info Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email Interests Computer skills Counseling Sign Language Office skills Teaching Foreign Language Public Speaking Legal Training Mediation Medical Training Other... Please check all of the skills or interests you have.Volunteer ExperiencePlease detail any experience you have as a volunteer Organization One Organization NameOrganization TypeJob TitleVolunteer durationi.e., Dec 2010 - Jan 2013 Organization Two Organization NameOrganization TypeJob TitleVolunteer durationi.e., Dec 2010 - Jan 2013 Other Volunteer and Community ActivitiesSpecial skills, interests and hobbiesEducation Name of SchoolMajor Areas of StudyDiploma/Degree earned Name of SchoolMajor Areas of StudyDiploma/Degree earned Name of SchoolMajor Areas of StudyDiploma/Degree earned Work ExperienceResumeAccepted file types: pdf, txt, rtf, doc, docx. Employers Most Recent Employer EmployerJob TitleDates employedi.e., Jan 2012 - March 2013Supervisor NameEmployer phoneType of BusinessYour job duties Previous Employer EmployerJob TitleDates employedi.e., Jan 2012 - March 2013Supervisor NameEmployer phoneType of BusinessYour job duties Assisted Living Facilities Assisted Living Past*YesNoHave you spent time (as a visitor, employee, volunteer or any other role) in nursing homes or assisted living facilities? If Yes, please list below: Facility One Facility NameFacility DatesYour role at the facility Facility Two Facility NameFacility DatesYour role at the facility Facility Three Facility NameFacility DatesYour role at the facility ReferencesPlease list 3 references (all 3 required) Reference One Name*Relationship*Phone*Email (preferred) Reference Two Name*Relationship*Phone*Email (preferred) Reference Three Name*Relationship*Phone*Email (preferred) Volunteer CommitmentHave you ever been convicted of a felony or misdemeanor?*YesNoAre you willing to undergo a criminal background check?*YesNoIf selected as a volunteer, are you able to complete 15 hours of training?*YesNoIf selected as a volunteer, can you make a one year commitment to the program?*YesNoWould you be available each month for Ombudsman home visits?*YesNoWhy do you want to be a long-term care ombudsman volunteer?*Conflict of InterestIf you are certified as a Volunteer Ombudsman you must avoid conflict of interest or the appearance of conflict of interest and cannot benefit financially from your affiliation with the Office of the Long-Term Care Ombudsman. If a conflict develops after your appointment as a volunteer, you must notify the office immediately.Do you have any financial or fiduciary interest in a long term care facility, corporation, or partnership that owns a long term care facility?*YesNoIs any member of your family employed in a long-term care facility or receiving income from one?*YesNoIs any member of your family or close friends currently residing in a long term care facility?*YesNoResponsibilitiesCertified Ombudsman are appointed by the State Long-Term Care Ombudsman to enhance the quality of life for the residents of long-term care facilities. Each Certified Ombudsman has statutory authority to enter a facility and approach residents and staff members in order to fulfill the program’s mission. Certified Ombudsman are obligated to respond to all complaints made by or on behalf of the residents. They serve as impartial fact-finders, problem solvers and resource brokers. Though Certified Ombudsman must be professional, impartial and fair in pursuit of their mission, they are first and foremost resident advocates and will approach every problem from this essential perspective.Consent and affirmationI hereby give my permission for the Office of Long Term Care Ombudsman to contact the persons I have listed as reference and any past employer to verify my suitability to perform the duties of a Volunteer Long Term Care Ombudsman for the State of Alaska. Checking the box below affirms the statements made in this application are true, accurate and complete to the best of my knowledge.I agree*I agreeI do not agree*Upon completion of application, all prospective volunteers will be interviewed in person or via phone.* This iframe contains the logic required to handle AJAX powered Gravity Forms.