volunteer application

In order to protect the security and safety of patients, caregivers and staff, Help In Healing Home does not allow volunteers under civil protection orders, individuals who are on probation, listed on a sex offender registry or found guilty of a criminal offense to volunteer at our facility.

Due to the compromised immune system of our guests, no one who has been exposed to or has been in contact with a person who has confirmed COVID-19 or other flu viruses, MRSA, Ebola, C-difficile or other communicable disease may be on the premises or volunteering in any activity which brings them into contact with our guests and staff.

The organizing entity for volunteer activities has the responsibility to ensure these guidelines are observed. Help In Healing Home is grateful for your willingness to provide support to our mission.

Volunteer Participation Agreement

By submitting and signing this volunteer application, you are acknowledging any information presented in relation to your interest in becoming a Help In Healing Home Volunteer is completed and true to the best of your abilities. Please sign and submit this form as an approval for a staff member to contact you and the references provided and to conduct a basic background check as required.

Interested Volunteer Full Name *

Home Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Home Phone

Cell Phone

Email *

Email

Confirm Email

Are you a student?

• Yes
• No

Emergency Contact - Full Name

Emergency Contact - Relationship

Emergency Contact - Home Phone

Emergency Contact - Cell Phone

Do you have any physical limitations that you wish us to consider in your volunteer placement?

Reference 1 - Full Name

Reference 1 - Relationship

Reference 1 - Phone

Reference 2 - Full Name

Reference 2 - Relationship

Reference 2 - Phone

SIGNATURE - Indicates agreement

PARENT/GUARDIAN SIGNATURE (IF UNDER 18)

Name

Submit