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2. 
3. Portage Manor Volunteer Form
5. *An approved Volunteer is here to benefit the resident's and facility at all times; the best interest of residents and facility will be maintained. A Volunteer can be dismissed at any time with or without cause and at the discretion of the Administrator.
7. Date(s) requesting to volunteer*
9. Department of Interest*

   Check one or more boxes

   1. Activities
   2. Dietary
   3. Front Office
   4. Housekeeping
   5. Maintenance
   6. Social Services
10. Skill or Training that makes you a good candidate for volunteering:
12. What interests you about Portage Manor?
14. What would you like to accomplish through volunteering at Portage Manor?
16. Is volunteering:

    1. A court ordered community service?
    2. A requirement for a class?
    3. A part of an internship?
17. If you checked a box, please explain:
21. Contact Information
23. First Name
24. Last Name
26. Address
28. City
29. State
30. Zip Code
32. Preferred method of contact:

    1. Phone
    2. Text
    3. Email
    4. Other
33. If other, please explain
35. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
37. Electronic Signature
41. Emergency Contact Information
    Used in the event of an unforeseen emergency
43. Contact Name
44. Contact Phone #
46. Address
48. City
49. State
50. Zip Code
52. Relationship to Applicant:
54. Signature of Volunteer
55. Date:
    Date:
57. Signature of Social Service Director/Designee
58. Date:
    Date:
60. Signature of Department Leader Assigned to
61. Date:
    Date:
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

* indicates a required field