Volunteer Application – Silver Spring Village

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APPLICANT INFORMATION

Name*

First Last

Preferred Name/Nickname*

Address*

Street Address Address Line 2 City State ZIP Code

Phone (preferred)*

Phone Type*

Alternate Phone

Alternate Phone Type

Email*

VOLUNTEER INTERESTS

What services are you able to provide to Village members?

Check all that apply

Decluttering Small Spaces (e.g., closets, cabinets, a single room) [Additional training offered]

Driving (DMV area)

Errands (e.g., grocery, pharmacy, post office) [Does not involve driving a member]

Friendly Phone Calls

Friendly Visits—In Person

Friendly Visits With Members Experiencing Cognitive Loss—In Person

Handyperson Tasks (e.g., fixing leaky faucets, installing grab bars, assembling furniture)

Household Tasks—Indoor (e.g., changing light bulbs, hanging pictures)

Household Tasks—Outdoor (e.g., seasonal cleanup, garden preparation, trimming)

Medical Notetaking [Additional training offered)

Tech Support—Smart Home (e.g., thermostats, doorbell cameras, alarm systems, voice-activated assistants)

Tech Support—General (e.g., computers, smart phones)

Temporary Pet Care (e.g., walking and feeding during a hospitalization or other short period)

Temporary Plant Care (e.g. watering during a hospitalization or other short period)

Weather Buddy (checking on a member before and after storms, heat waves, or other inclement weather)

Other

Please describe your other direct service volunteer interests

What organizational/administrative servicse are you able to provide?

Check all that apply

Fundraising

Guest Speaker Event Planning (e.g., arts & culture, health & wellness, local/regional interest)

Legal Advice

Marketing & Communications

Social Media Planning

Other

Please describe your other organizational/administrative volunteer interests

VOLUNTEER AVAILABILITY

Weekdays*

Check all that apply

Mornings

Afternoons

Evenings

Not Available

Weekends*

Check all that apply

Saturdays

Sundays

Not Available

FOR VOLUNTEER DRIVERS ONLY

Please mail a copy of your driver's license (both sides) and auto insurance card to Silver Spring Village, ATTN: Volunteers, 8700 Georgia Ave Ste 306, Silver Spring, MD 20910 (or email to volunteers@silverspringvillage.org).

Driver’s License State:*

Driver’s License Number*

Driver’s License Expiration Date:*

Auto Insurance Carrier*

Auto Insurance Policy No.*

EMERGENCY CONTACTS

Emergency Contact(s)*

Please provide the information for at least one emergency contact. Click the blue + sign to add additional emergency contacts.

Name

Relationship To Me

Phone

Complete Address

REFERENCES

Please provide two references other than relatives who have known you for at least two years. If possible, include at least one person who has supervised your work in a paid or volunteer capacity.

Reference #1: Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship to me*

How long have have you known one another?*

Reference #2: Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship to me*

How long have you known one another?*

DEMOGRAPHIC INFORMATION

A response to each question is required. You may select "prefer not to answer," but we encourage responses to help us understand how well our volunteers reflect the diversity of Silver Spring. Personal demographic information is confidential and is reported only in non-identifiable aggregate form.

Birthdate*

Gender*

Other Gender Identity Description*

Preferred Pronouns*

Other Preferred Pronoun Description*

Ethnicity*

Race*

Other Race Description*

I identify as LGBTQ+*

Accommodation Needs*

Cognitive Impairment

Hearing Impairment

Low Vision

Mobility Impairment

None

Other

Other Accommodation Needs Description*

REFERRAL INFORMATION

Name of the Village volunteer or member who referred you for volunteering (if applicable)

Referring Volunteer/Member Name

VOLUNTEER AGREEMENT*

OUR SERVICES
Silver Spring Village (the “Village”) is a 501(c)(3) nonprofit Maryland corporation organized to sustain a robust network of neighbors-helping-neighbors that supports older adults who wish to live as independently as possible and be fully engaged in their community as they age. The Village accomplishes its mission by offering an array of social, educational, recreational, and cultural activities and third-party vendor recommendations for all members; and volunteer-provided direct services for Full Members only.

VOLUNTEER SCREENING
I understand that the Village will complete criminal background and reference checks on me. It will also complete a driving history check if I have indicated interest in serving as a volunteer driver. I understand that I may choose to pay the background check fee or have the Village pay that expense when I begin completing the background check form.

VOLUNTEER LIMITATIONS
Volunteers may not provide personal care services or home services that typically require professional licensing.

PHOTO/VIDEO RELEASE
The Village may use my likeness including but not limited to photographs and video and audio recordings, in both print and electronic form for promotional and educational purposes. Village events occurring in public spaces carry no expectation of privacy.

CONFIDENTIALITY
A acknowledge the privacy and dignity of all Village members and volunteers. Other than communicating essential health- or safety-related information to the Director of Volunteer Services or Executive Director, I will maintain strict confidentiality regarding any personal information that I may learn about Village members in the course of volunteering.

DUE DILIGENCE
I will not knowingly endanger the life, health or safety of an Village member or volunteer.

PERSONAL GAIN
I will not use my association with Silver Spring Village for personal gain and will not conduct myself in any way that negatively affects public confidence in the Village.

LIABILITY
In exchange for my acceptance as a volunteer, I agree to indemnify and hold harmless the Village against any and all loss, expense, liability arising from or in any manner related to the Village's performance and that of its agents and the activities of any member or other volunteer.

I have read and understand the above terms and conditions of volunteering, and agree that I and my heirs, successors, agents, and legal representatives are bound by said terms and conditions. These terms will remain in force for the full duration of my volunteer service.

Name*

First Last

Date

Signature*

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