The Foundation for Tender
Loving Care Touch
831 Bay Avenue Suite 1B, Capitola
CA 95010
Phone: (831) 334-0333
Email: ftlctouch@gmail.com
URL: www.tenderlovingcaretouch.org
Practitioner I University/College Volunteer Application
We Show Up and Love Grows!
GENERAL INFORMATION
Name (legal) ___________________________________________________________
Nickname or preferred name________________________________________________
Today’s Date________________________________________
Address_______________________________________________
Mailing address if different_____________________________________________
Phone(s) ______________________________________________________________
Email Address __________________________________________________________
Date of Birth:__________________________________
Occupation
Employer____________________________________________________________
How long have you been with
your current employer? _______________________
The number of hours weekly_____
Education
Area of Studies _____________________________________________________
Completed: _______________________________________________________
Degree_________
When will you graduate? _________________________
GENERAL INFORMATION
VOLUNTEER
INTEREST
How did you hear about our
organization?
What interests you in becoming
a volunteer?
What skills, talents and interests do you have that could apply to working as a volunteer with FTLCTouch?
Do you have additional skills
which you believe would be useful for FTLCTouch and our clients?
Areas of interest might be
art, music, performance, video production, web design or maintenance, office work, volunteer training, volunteer coordinating,
outreach
Have you had significant
losses in your life?
If so, please describe what and when they were
How did you deal with theses
losses? (Mentally, emotionally, physically, spiritually?)
What role did your family play in these losses?
Were there other people who
helped you deal with your loss? (Neighbors, volunteers, community support ……?)
What have you enjoyed most
in previous volunteer assignments?
.
What have you least enjoyed?
Have you had previous training which would be useful in your volunteer practitioner work with FTLCTouch?
Are you familiar with NICU,
PECU, Subacute care, Family Home Respite Centers hospice care, Mental Health, children with special needs or any other areas
of wellness which address families living with life limiting or chronic conditions of loved ones?
If yes, please explain:
Are you knowledgeable about
any other illness or condition?
Do you currently work with
hospice care patients, hospitalized children, and/or seniors?
If yes, which and in what
capacity?
Do you have concerns associated
with working with hospice care patients, seniors or special needs children?
If yes, what are your concerns?
Would you be willing to travel
to your client’s home?
If yes, to what areas would
you be willing to travel? ________
___________________________________________________
Do you have access to reliable
transportation to perform your volunteer work?
Do you have a valid driver’s
license?_______________State?_______
Do you have automobile liability
insurance? ________________________
Language(s) spoken,_____________________________________________
Are you currently certified
in CPR?
Have you ever been convicted
of a felony?
If yes, explain
__________________________________________________________
REFERENCES
Reference #1
Name: ____________________________________________
Relationship: ______________________________________
Phone number: _____________________________________
Reference #2
Name: ___________________________________________
Relationship:
_______________________________________
Phone number: _______________________________________
Reference #3
Name: _______________________________________________________
Relationship: __________________________________________________
Phone number: ________________________________________________
University/College
Volunteer Application
COMMITMENT
TO PARTICIPATE in VOLUNTEER TRAINING AND HOURS
I, ________________________________________________________________,
am committed to participating in this training(s)
I am able to volunteer for
2 hour(s) a week for 3 months
And
I have cleared my schedule
so that I can participate in the two weekend workshops and the weekly evening class.
I have written the dates
for this training into my calendar or schedule.
If I can not participate
fully in this training, I agree to contact the Foundation for Tender Loving Care Touch office to make possible arrangements
as soon as I know of this.
I understand that there
is a $650 workshop and materials fee for this class. This fee is not refundable after the first Friday prior to the beginning of classes.
(Please sign and date):
Signature: _____________________________________________________________
Date:
_______________________________________________________________
Ethnic and Cultural and Religious/Spiritual
Affiliations and Identifications (OPTIONALS):
Hispanic/Latino
White
Any particular country(s)
Black/African American
Asian
Native American
Pacific Islander
Other
I hereby authorize Foundation For Tender Loving Care Touch
(FTLC Touch)and any authorized agent acting on its behalf to prepare a criminal investigative report on my background. I therefore authorize, request and require any persons or institutions contacted to
furnish Foundation For Tender Loving Care Touch (FTLC Touch) or its agents any information they have concerning any criminal
and/or motor vehicle conviction records, my work history and achievements, education history and achievements and general
reputation and character.
As an inducement to provide this information,
I hereby release and forever discharge each and every such person or institution from any and all claims of liability, in
law or in equity, that may arise out of furnishing such information to
Foundation For Tender Loving Care Touch (FTLC Touch)
or any authorized agent of that company.
I may, upon written request, receive further
information as to the nature and scope of such investigation. Any inquiries are
to be directed to the agency/company as listed in the two preceding paragraphs.
My signature below indicates my understanding
and acceptance of all the above terms and stipulations.
Additional Information for Health Workers and Practitioners
PRACTITIONER INFORMATION
What type of healthcare practitioner
are you? (i.e., massage therapist, nurse, chiropractor, physical therapist,
Acupuncturist, etc.) ?
_____________________________________________________________
Are you certified?
Yes
No
If no, when will you be certified?
_____________________________________
Educational background/training:
________________________________________________________________________
Are you currently working
as a health care practitioner?
Yes? If yes, where _______________________________________________________________________
________________________________________________________________________
Are you an active member
of any professional organizations?
Please list names of organizations: ____________________________________________________________________
Are you currently certified
in CPR?
Do you currently carry malpractice
insurance?
If so, with whom? _____________________________
