Thank you for your interest in volunteering for the Long-Term Care Ombudsman Program. We appreciate you taking the time to fill out our form.

Required information shown with *

First Name(s) *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Phone * --- Home Mobile Work Fax

Alt Phone * --- Home Mobile Work Fax

Email *

Emergency Contact

Emergency Contact Phone * --- Home Mobile Work Fax

If you are currently working, who is your employer?

What is your occupation?

Please tell us about your education and background experience.

Please tell us about your related experience.

Please tell us about your other volunteer experience.

Please describe your interest in advocating for people receiving long-term care services.

Why are you interested in being a Long-Term Care Ombudsman Volunteer?

Are you over the age of 18? * --- Yes No

Have you ever been arrested or convicted of anything other than a traffic violation? * --- Yes No

Please indicate when you are available for training.

9am-12pm weekdays * --- Yes No

9am-12pm Saturdays * --- Yes No

12pm-5pm Saturdays * --- Yes No

How did you hear about our program? --- Media General Knowledge/Previous Contact Government Agency Internet Lawyer Community Organization Family/Friends Word of Mouth Other

If "Other", what?