Volunteer Application Contact Info Name* First Last Phone*Email Date of birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you lived in other states? (if so, where and when)*Why do you want to be a long-term care ombudsman volunteer?*Do you have special skills to share with the program? (foreign languages, PR, IT, social media, etc.)How did you hear about volunteer opportunities with our office?Education (highest level completed)Name of SchoolDiploma/Degree earnedMajor Area of Study (if applicable)Work ExperienceResumeAccepted file types: pdf, txt, rtf, doc, docx.Current EmployerName of BusinessAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates employedi.e., Jan 2012 - March 2013Supervisor NameSupervisor phoneSupervisor email Job TitleYour job dutiesHave you been at this job more than 5 years?YesNoPrevious Employer (1)Name of BusinessAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates employedi.e., Jan 2012 - March 2013Supervisor NameSupervisor phoneSupervisor email Job TitleYour job dutiesHave you entered 5 years of employment history?YesNoPrevious Employer (2)Name of BusinessAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates employedi.e., Jan 2012 - March 2013Supervisor NameSupervisor phoneSupervisor email Job TitleYour job dutiesVolunteer Experience (most recent first)Please detail any experience you have as a volunteerOrganization NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates of volunteer positioni.e., Dec 2010 - Jan 2013Supervisor NameSupervisor PhoneSupervisor Email Volunteer TitleVolunteer dutiesDo you have more volunteer history?YesNoVolunteer History (previous volunteer experience)Organization NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates of volunteer positioni.e., Dec 2010 - Jan 2013Supervisor NameSupervisor PhoneSupervisor Email Volunteer TitleVolunteer dutiesReferencesPlease list 3 references, at least one must be a professional reference Reference One Name* First Last Relationship*Phone*Email (preferred) Reference Two Name* First Last Relationship*Phone*Email (preferred) Reference Three Name* First Last Relationship*Phone*Email (preferred) Volunteer CommitmentAre you able to complete 36 hours of mandatory orientation training?*YesNoAre you able to make a one-year commitment to the program?*YesNoAre you able to make monthly visits to facilities (2-4 hours)?*YesNoAre you able to attend a monthly 1.5 hours of continuing education training (at noon on the 3rd Wednesday of the month)?YesNoConflict of InterestAll Long Term Care Ombudsmen must avoid conflict of interest or the appearance of a conflict of interest. They cannot benefit financially from an affiliation with the OLTCO in any way.Do you have any financial or fiduciary interest in a nursing facility or assisted living home, corporation or partnership?*YesNoAre you or is any member of your family employed in or receiving income from a nursing facility or assisted living home?*YesNoIs any member of your family or close friends currently residing in a long term care facility?*YesNoHave you spent time as a visitor, employee, volunteer or any other role in an assisted living home or nursing facility?YesNoHave you ever been convicted of a felony or misdemeanor?*YesNoIf yes, please explain below.Are you willing to undergo a criminal background check?*YesNoResponsibilitiesLTC Ombudsmen are appointed by the State Long Term Care Ombudsman to enhance the quality of life for the residents of nursing facilities and assisted living homes. Each Volunteer Long Term Care Ombudsman (VLTCO) has statutory authority to enter a facility and approach residents and staff members in order to fulfill the program’s mission. All VLTCO are obligated to respond to all complaints made by or on behalf of residents in their facilities. All VLTC Ombudsmen are advocates for residents and follow the resident’s direction to resolve issues.Do you agree to abide by these responsibilities?YesNoConsent and affirmationBy checking the box below, I give permission for the Office of Long Term Care Ombudsman to contact the persons I have listed as references and any past employers as well as perform a background check to verify my suitability to perform the duties of a Volunteer Long Term Care Ombudsman for the State of Alaska.*I agreeBy checking the box below, I affirm that the information in this application is true, accurate and complete to the best of my knowledge.*I agreeUpon completion of this application, all prospective volunteers will be contacted by Kathryn Curry to be interviewed in person or via phone. This iframe contains the logic required to handle Ajax powered Gravity Forms.