Achieva Resources Corporation, Inc.
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Achieva resources VOLUNTEER Advocacy Services
Volunteer Application Form
Part 1 - Personal History
A. General History
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Indicates required field
Name
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First
Last
Address
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City
State
Zip Code
Country
Phone Number
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Email
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Are you a US Citizen?
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Yes
No
Date of Birth
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Gender
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Male
Female
Employer
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May we call you at work?
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Yes
No
Employer Address
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Line 1
Line 2
City
State
Zip Code
Country
Employer Phone Number
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Spouse
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Spouse Occupation
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Spouse Employer
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Spouse Employer Phone Number
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Child #1
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Child #1 Birthdate
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Child #2
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Child #2 Birthdate
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Other Members in your household
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Relationship of other members?
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Emergency Contact
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Emergency Contact Phone Number
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Emergency Contact Address
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Line 1
Line 2
City
State
Zip Code
Country
Describe the Condition of your general health
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Please describe any limitations that could interfere with your performance as a volunteer guardian
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Name of community and religous organizations or clubs you hold membership in
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Current/past offices held
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B. Transportation
Do you have a valid driver's license?
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Yes
No
Drivers License Number
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Do you have a car available to you?
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Yes
No
Auto Insurance Company
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Liability Limits
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Auto Insurance Policy Number
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C. Employment/Volunteer Work History
Present employer/volunteer program
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Dates you began employment/volunteer work
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Job Description
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Employer/Volunteer Present Address
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Line 2
City
State
Zip Code
Country
Employer 1 Phone Number
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Previous employer/volunteer program
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Previous dates of employment/volunteer work
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Previous Job Description
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Previous Employer/Volunteer Address
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Line 1
Line 2
City
State
Zip Code
Country
Previous Employer/Volunteer Phone Number
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Previous employer/volunteer program 2
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Previous dates of employment/volunteer work 2
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Previous Job Description 2
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Previous Employer/Volunteer Address 2
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Line 1
Line 2
City
State
Zip Code
Country
Previous Employer/Volunteer Phone Number 2
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D. Education/Training Experience
Did you graduate from high school?
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Yes
No
Name of School and Year Graduated
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Did you attend college or technical/trade school?
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Yes
No
Name of College/Trade schools and year graduated
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College Degree and/or Professional trade licenses held?
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Other Educational/Training programs completed
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Do you have training and/or work experience in any of the following areas?
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counseling
criminology
drug/alcohol
education
geriatric care
health care
mental health
news media
nursing
office administration
law
public speaking
law enforcement
psychology
social work
writing
Other (Please explain)
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If yes, please describe experience
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Do you speak Spainish or another foreign language?
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Yes
No
If yes, please explain
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E. Legal History
Have you ever been arrested, indicted, or charged with a misdemeanor or criminal offense?
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Yes
No
If arrested, indicted or charged, please explain
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Have you been convicted of a misdemeanor or criminal offense?
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Yes
No
If convicted please explain
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Have you ever been charged or convicted of a DUI or reckless driving traffic offense?
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Yes
No
If charged for DUI or reckless driving please explain
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Have you ever been involved as a party in a probate court case?
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Yes
No
If you have been involved, please explain
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Have you ever been the subject of a child abuse, domestic violence, or adult protective services investigation?
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Yes
No
If yes, please explain
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Part 2 - Motivation and Life History Information
Please answer the following questions in paragraph form
Write a short summary about your interest in volunteering and how you hope to benefit from your experience with ARAGS Program
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Briefly explain what led to your decision to apply to become a volunteer guardian with the ARAGS Program? (What attracted you to this particular program?)
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Briefly explain your philosophy on aging including the rights of the elderly and disabled
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Briefly explain what role you believe society should play in: a protecting the elderly, b. helping the elderly and disabled to overcome hardships and remain living independently
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Please write a page autobiography
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Part 3 - Personal References
Achieva Resources requires three personal or professional references to complete the Volunteer Application. Please print the names, addresses, zip codes and telephone numbers of three people who have known you for a minimum of
two years.
The references need to be individuals who can address how well you relate to elderly and/or incapacitated persons and how well you can fulfill the responsibility of being a Achieva Resource Volunteer Advocate.
Please do not include relatives
. Achieva Resources staff will contact the references by mail.
Reference 1
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First
Last
Reference 1 Relationship
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Reference 1 Length of acquaintance
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Reference 1 Phone Number
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Reference 1 Address
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Reference 2
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First
Last
Reference 2 Relationship
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Reference 2 Length of acquaintance
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Reference 2 Phone Number
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Reference 2 Address
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Reference 3
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First
Last
Reference 3 Relationship
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Reference 3 Length of acquaintance
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Reference 3 Phone Number
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Reference 3 Address
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Part 4 - Affirmation and acceptance
I hereby affirm that all the answers on the above Volunteer Application for the Volunteer Advocate Program are true to the best of my knowledge. I hereby authorize the Volunteer Advocate Program and to investigate my background to determine my fitness as a potential Volunteer Limited Guardian. I understand that the information requested in this application will be used only for the purpose of determining my suitability as a volunteer.
Furthermore, I understand that after the successful completion of my training, I will be expected to serve a minimum of one year or for as long as the incapacitated person's case to which I am assigned is being supervised by the Volunteer Advocate Program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the Volunteer Advocate Program as soon as possible.
I am aware of the sensitive and
confidential
nature of the official documents, reports and other materials I will examine in my capacity as a Volunteer Advocate. I promise that I shall hold all pertinent information in strict confidence. I will only discuss the contents of these materials with those persons who are parties to the case and their legal representatives or with persons or organizations that may be consulted for professional knowledge or expertise. I will not remove any written records from the Volunteer Advocate Program office without expressed permission. I accept full responsibility for maintaining the confidential and private nature of all records and information. I understand that I am personally responsible and liable for any violation of this statement.
Electronic Signature
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First
Last
Electronic Signature Date
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Electronic Signature Address
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Line 1
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City
State
Zip Code
Country
Electronic Signature Email
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Submit
Achieva Resources Corporation, Inc., P.O. Box 1252, 800 Mendleson Drive, Richmond, Indiana 47375
Phone: 765-966-0502 Fax: 765-962-3179