Volunteer Resident Advocate Application Form

Connecticut Long Term Care Ombudsman Program Resident Advocate Application

First Name*

Last Name*

Address*

Address street

Street Address Line 2

CityState

Zip

Phone*

Please Enter xxx-xxx-xxxx

Date of Birth*

MonthDayYear

Social Security Number*

Gender

MaleFemale

Indicate Highest Level of Education*

High SchoolCollegeTechnical SchoolOther

Employment Experience (include present employment):*

Foreign languages spoken

Any Physical Limitations?*

YesNo

If Yes, Please Explain*

Have you ever been a volunteer?*

YesNo

If Yes, Where? Dates: Describe Activities*

List memberships in civic/fraternal/church or other organizations:*

If yes describe briefly*

Have you ever had any experience with nursing homes or working with the elderly/disabled?*

YesNo

If Yes, Please Describe Experience with Nursing Homes or working with the Elderly/Disabled*

Do you or a family member currently work in or own a long-term care facility?*

YesNo

Please Describe the Work That you Or Your Family Member Do in a Long-Term Care Facility*

Do you have a relative in a long-term care facility at the present time?*

YesNo

If Yes, Where?*

(Individuals who work or live in a facility are resticted from Volunteering.)

(Individuals who have a family member live in a long term care facility are restricted from volunteering in any home associated with that facility/entity.)

Can you spend four hours a week as a Volunteer Resident Advocate in an assigned facility?*

YesNo

Can you attend five days in an initial training program?*

YesNo

Are You Available for Additional 2 hour Trainings and/or group meetings every month?

YesNo

Do you have a Driver's License and valid Auto Insurance?*

YesNo

Drivers License Number*

Upload Copy of Driver ID

Name of Insurance Carrier and Policy #*

Do you Have Access to a Car?

YesNo

Upload Proof Of Insurance

Write a brief statement as to why you want to be a Volunteer Resident Advocate:*

How did you learn about this program*

Race (Optional)

WhiteBlackHispanicOther

Applicant Signature*

Date*

MonthDayYear

You will be asked to provide two references from non-related persons. If applicable, former supervisors would be appropriate. Please send completed application and completed references to:

State Ombudsman/Mairead Painter

State Long Term Care Ombudsman Program Department of Aging and Disability Services Email LTCOP@ct.gov