SENIOR COMPANION PROGRAM

3519 N. Richmond Road McHenry, IL 60051 (815)344-3555

Volunteer Application

The information that you have been asked to provide is for the purpose of arranging a suitable friendly visitor, phone companion, nursing home visitor or canine companion match with a qualified senior. Acceptance of this application is not a guarantee that an appropriate match can or will be made. We make every effort to maintain confidentiality regarding personal information given.

Name: Click here to enter text.	Date: Click here to enter text.

Address: Click here to enter text.

City: Click here to enter text.Zip:Click here to enter text.Birth date: Click here to enter text.

Home phone: Click here to enter text.Work/cell phone: Click here to enter text.

E-mail: Click here to enter text. Marital status: Click here to enter text.

Emergency contact: Click here to enter text. Relationship: Click here to enter text.

Emergency Contact Phone: Click here to enter text.

Employment: F/T	☐ P/T ☐ Retired ☐	Other ☐

Are you a veteran? Yes: ☐ No: ☐

Driver’s license No./State : Click here to enter text. Expires: Click here to enter text.

Car Insurance Company: Click here to enter text.

How far are you willing to travel to visit your senior? Click here to enter text.

Do you have a gender preference? Yes: ☐ No: ☐ If Yes, which: Click here to enter text.

Are you comfortable with pets? Yes: ☐ No: ☐If No, which: Click here to enter text.

Are you sensitive to smoking or smoke odor? Yes: ☐No: ☐

VOLUNTEER REFERENCES

Your Name: Click here to enter text.

(Please Print Clearly)

1. Reference (non-relative): Click here to enter text.

E-mail Address: Click here to enter text.

Address: Click here to enter text.

City, State, Zip: Click here to enter text.

Phone: Click here to enter text.

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2. Reference (non-relative): Click here to enter text.

E-mail Address): Click here to enter text.

Address: Click here to enter text.

City, State, Zip: Click here to enter text.

Phone: Click here to enter text.

CONSENT FOR CRIMINAL BACKGROUND CHECK

I hereby give my permission for the Illinois State Police to obtain information relating to my criminal history record through Senior Services Associates, Inc. The criminal history record, as received from the reporting agencies, may include arrest and conviction data. I understand that this information will be used in part, to determine my eligibility for a volunteer position with this organization. I also understand that as long as I remain a volunteer here, the criminal history records check may be repeated at any time.

I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received. I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify and hold the Senior Services Associates, Inc. and officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debits and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer.

Applicant’s Signature :

Print Name: Click here to enter text.

Maiden Name: Click here to enter text.

Sex: Click here to enter text. Race: Click here to enter text.

Date of Birth: Click here to enter text.

Today’s Date: Click here to enter text.

Office: _______MCHENRY_________ Submitted by:__________________________ Date: ____________________

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OFFICE ONLY: Volunteer will be: (circle as many as needed):

Elgin Trans	Kendall Trans	McHenry Trans

Elgin/Kane RSVP	Kendall RSVP	McHenry RSVP

Kane Trans	Kendall Sen. Comp.	McHenry Sen. Comp.

Kane/Aurora Sen. Comp.	Other:______________________________________________________

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SENIOR SERVICES ASSOCIATES, INC.

________________________________________________________________________

CONFIDENTIALITY AGREEMENT

______________________

This Confidentiality Agreement (“Agreement”) is made and entered into by and between Senior Services Associates, Inc., including its subsidiaries and operating units (“Senior Services Associates, Inc.”) and the individual whose name is set forth at the bottom of this Agreement (“Individual”), as of the date set forth below. For and in consideration of Individual’s access to and use of the Confidential Information (defined below), and for other good and valuable consideration, the receipt, sufficiency, and adequacy of which are hereby acknowledged. Individual agrees as follows:

Individual acknowledges and agrees that, by virtue of Individual’s association with Senior Services Associates, Inc., through employment, consultation, or otherwise. Individual may be granted access to certain Confidential Information of Senior Services Associates, Inc. and Senior Services Associates, Inc. clients. For the purposes of this Agreement, “Confidential Information” shall mean; Client Health Information (defined below); any and all information and data relating to Senior Services Associates, Inc., clients, financial information including, but not limited to, billing procedures, forecasts, projections, fee schedules and accounting information, and personnel information. “Client Health Information” shall mean individually identifiable health information of a Senior Services Associates, Inc. client.

Individual acknowledges that Senior Services Associates, Inc. (or, as the case may be applicable Senior Services Associates, Inc. client), shall retain ownership of all right, title, and interest in and to the Confidential Information, including, but not limited to, any and all worldwide copyright, patent, trademark, trade secret and other intellectual property rights thereto, and no such rights are transferred to individual hereunder or by virtue of individual’s access to the Confidential Information.

Individual shall not, directly or indirectly, disclose, copy, distribute, republish or allow access to any Confidential Information except permitted herein.

Individual shall limit his/her access to and us of the Confidential Information solely to that access and use as specifically required by individual’s duties for Senior Services Associate, Inc. In the event individual is a Health Care Provider (defined below), Individual acknowledges and agrees that individual’s use of client Confidential Information shall be limited to that use required (a) in order to facilitate treatment of the client, (b) in order to facilitate payment for health care services rendered, and/or (c) for internal quality oversight review; provided, however, that the Health Care Provider shall not be permitted to disclose psychotherapy notes regarding a client unless prior authorization is first obtained from the client. The Individual shall, in accessing the using the Confidential Information, comply with Senior Services Associates, Inc. security policies related to the use of such Confidential Information and refrain from using or disclosing more than the minimal amount of Confidential Information necessary to accomplish the intended purpose of the use or the disclosure. For the purpose of this Agreement “Health Care Provider” shall mean a provider of medical services as defined in Section 1171 (3) of the Social Security Act, a provider of medical or other health services as defined in Section 1861 (s) of the Social Security Act and any other person who furnishes health care services or supplies.

Individual may disclose Confidential Information if so required by law (including court order or subpoena), provided that Senior Services Associates, Inc. may required individual to request the appropriate court of governmental body to seal the record that shall contain such Confidential Information.

Upon learning of (a) any unauthorized disclosure or use of Confidential Information, or (b) any requirement to disclose such Confidential Information by operation of law, regulation or other legal process, Individual aggress to notify Senior Services Associates, Inc. immediately, and to cooperate fully with Senior Services Associates, Inc. to protect the confidentiality of such Confidential Information.

Upon request of Senior Services Associates, Inc., or upon termination of Individual’s involvement with Senior Services Associates, Inc., whether through termination of employment, termination of engagement, or otherwise, individual shall return to Senior Services Associates, Inc. all Confidential Information furnished to Individual without retaining any copy thereof.

Individual acknowledges and agrees that any breach of this Agreement will cause immediate and irreparable injury to Senior Services Associates, Inc., that monetary damages will in inadequate to compensate for such breach, and that, in the event of such breach, Senior Services Associates, Inc. shall be entitled to seek injunctive relief, and any and all remedies available at law or inequity.

Individual shall maintain such safeguards and engage in such practices as necessary to ensure that the Confidential Information is adequately protected, including, but not limited to, engaging in the following practices, as applicable:

not making inquiries with respect the Confidential Information for other personnel who do not have proper authority;

not disclosing any computer passwords or access numbers to others;

not making any unauthorized transmissions, inquiries, modification, or purging of data in Senior Services Associates, Inc. information systems; and

login off from any computer or access terminal prior to leaving any such computer access terminal unattended, unless a password protected screensaver is activated.

not removing client files and other confidential information, for any reason, from the individual’s Senior Services Associates office.

asking client, when interviewing in a public area, if they would be more comfortable in a private setting.

Individual acknowledges and understands that all access by Individual to Senior Services Associates, Inc. information systems will be monitored. (e-mails are the property of Senior Services Associates, Inc. and will be treated as same.)

Individual acknowledges and agrees that any client whose client Confidential Information is accessed or used by Individual in the course of Individual’s performance of his / her obligations for Senior Services Associates, Inc. is intended to be, and shall be treated as, a third party beneficiary to this Agreement.

Individual acknowledges and agrees that Senior Services Associates, Inc. shall have the right in its solo discretion, to terminate Individual’s access to the Confidential Information , and terminate any underlying contractual agreement pursuant to which individual required access to such Confidential Information, including, but not limited to, any employment agreement, consulting agreement, or other similar arrangement, in the event individual breaches the terms of the Agreement. Nothing in this paragraph shall be construed as limiting Senior Services Associates, Inc. from seeking any other remedies or damages from individual in the event of such a breach, whether in law or in equity.

If any provision of this Agreement is held invalid by a court or competent jurisdiction, such invalidity shall not effect the enforceability of any other provisions contained in this Agreement, and the remaining portions of this Agreement shall continue in full force and effect.

This Agreement represents the complete and exclusive statement of the mutual understanding of the parties with respect to the subject matter hereof and supersedes and cancels all previous and contemporaneous written and oral agreements and communications raising to the subject matter of this Agreement.

This Agreement shall be governed by, Interpreted and construed in accordance with the laws of the State of Illinois.

Signature:

Print Name: Click here to enter text.

Date: Click here to enter text.

VOLUNTEER AGREEMENT

By signing below, you understand and agree to the following:

This acceptance is made by Name of Volunteer

with the understanding that I hereby waive, release and discharge any and all claims of damages for personal injury, property damage or death, which I may have or which may hereafter accrue to myself, as a result of my participation in the Senior Companion Program. This release is intended to discharge The Senior Companion Program from any and all claims of negligence or carelessness of these individuals in the selection of a senior. I hereby agree to assume for myself any and all risks involved in participation in The Senior Companion Program, and to release and hold harmless all persons or officials mentioned above, who, through negligence or carelessness, might otherwise be liable to me or my heirs or assigns for damages. It is further understood that this waiver, release and assumption of risk are to be binding upon heirs and assigns of myself.

I authorize Senior Services Associates, Inc. of McHenry County to investigate my background and check all references given. I hereby give my consent for this information exchange and authorize such agencies and/or individuals to release any information requested by Senior Services Associates, Inc. I understand that those to be contacted may include but not be limited to employers, courts, police, social service agencies and any other persons or agencies. I understand that procurement of this background information by Senior Services is not a guarantee that an appropriate match can or will be made.

I hereby give permission to Senior Services Associates, Inc. and the Senior Companion Coordinator to release my file to funders of the Senior Companion Program for audit purposes.

I understand that if I use my personal automobile to, from and during my volunteer assignment, I will arrange to keep in effect automobile liability insurance equal to or greater than the minimum required by the state.

I have read the responsibilities & goals of the volunteer for this position (copy provided) and agree to adhere to the volunteer regulations.

I have no criminal record or charge and been convicted of no criminal offenses, except:

____________________________________________________________________________

I am not chemically dependent on any substance including alcohol, marijuana, valium, or any other drug.

I have never physically battered, abused, sexually assaulted, or mistreated any person.

I have no history of mental health problems, or mental illness, except: ___________________

____________________________________________________________________________

Volunteer Signature: ________________________________________________________________

Date (expires 1 year from date recorded): Click here to enter text.

*VOLUNTEER COPY*

SENIOR COMPANION PROGRAM

RESPONSIBILITIES & GOALS OF THE VOLUNTEER

The volunteer should begin the relationship with the intention that he/she can make weekly contact with his/her assigned senior for no less than one year. However, exceptions can be made upon discussion with the program coordinator.

The volunteer needs to be prompt and dependable, avoiding disappointing cancellations.

If a situation arises where it is impossible for the volunteer to see his/her senior, he/she needs to explain the situation to the senior. If it is a temporary situation, the senior will understand. If it is to be permanent, please notify the program coordinator so a replacement can be found. The volunteer will not just disappear from the match.

The volunteer will maintain contact with the Senior Companion Program Coordinator by responding to calls, letters, e-mails and will complete surveys as requested by the Coordinator.

The volunteer will not accept monetary compensation as a companion to a senior.

The volunteer needs to work with Senior Services staff if he/she feels any referral services are needed.

Absolutely NO consumption of alcohol, drugs or mind-altering substances are allowed while on a volunteer assignment. The volunteer will be of clear mind, sober and able to provide safe companionship.

If a change in the senior’s physical or mental abilities is noticed, the volunteer will inform the caregiver and the program coordinator immediately.

In the event of an emergency, the volunteer will call 911 for assistance.

If any type of Elder Abuse (i.e. physical, financial, emotional, etc.) is suspected, notify Senior Services IMMEDIATELY. Your call will be handled confidentially as Senior Services is state mandated to investigate any reports.

The volunteer will notify the program coordinator of all changes of phone numbers and address.

The volunteer will notify the program coordinator if they are conflicting with their senior or they are not bonding with them. Sometimes people just do not click with each other.