NE Seniors for Better Living Volunteer Form
If you have any questions regarding this form, please contact our office at or call 651-808-1901.

The undersigned wishes to participate on a voluntary basis for North East Neighborhoods Living at Home/Block Nurse Program (NE Seniors for Better Living).

PARTICIPANT ASSUMES RISK: Participant is aware of and understands the inherent risk and dangers associated with a physical activity and agrees to assume all risk and responsibility for personal injury or death or damage to property arising from, based upon, or relating to the participation in the event. Participant is in good physical condition, is physically able to participate in this activity, and has no health or medical conditions which would pose a risk of harm to themselves or others.

RELEASE FROM LIABILITY: In consideration of the opportunity afforded to me to assist on a voluntary basis, Participant agrees to release North East Neighborhoods Living at Home/Block Nurse Program (NE Seniors for Better Living), its employees, officers, directors, or agents, from any and all liability from claims of any nature arising from undersigned’s participation.

PERMISSION FOR USE OF PHOTO FOR PROMOTIONAL MATERIALS: I do hereby grant and give these groups the right to use my photograph or image with or without my name, both single and in conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity, and promotions relating thereto.

I hereby agree to perform the volunteer duties assigned in said volunteer event to the best of my ability and in a professional manner and to the use of my photo image and name as described above.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

BACKGROUND CHECK CONSENT: I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record information to North East neighborhoods Living at Home/Block Nurse Program (DBA North East Seniors for Better Living) for the purpose of volunteering with this organization. The expiration of this authorization shall be one year from the date of my signature.

PROTECTING CONFIDENTIALITY & PRIVACY: By volunteering with our clients, you may find the person grows to trust you and begins to share personal and private information. We are a nonprofit that thrives on natural helping relationships and friendships among neighbors. The close circles in which volunteers, seniors/clients, and staff interact in the neighborhood and at our office make it vitally important that volunteers learn to keep confidential information that a client may share.

There are important distinctions to be made among different kinds of information. Some info is public knowledge, for example, that a person’s spouse has died. Some information is based not necessarily on facts, but on people’s interpretations of what they believe to be true. For example, some people discuss that the widow must not be grieving because people haven’t seen them crying. As a volunteer, you should never engage in interpreting the situation of a senior or others. Finally, some information is private knowledge. This is the kind of information that may be made available to you in your role as one of our volunteers and which you are required to keep confidential.

There may be a great temptation as a volunteer to discuss private knowledge with others to correct their erroneous interpretations. As right as this may seem, it is NOT appropriate to share private knowledge under any but the following circumstances:

Information, even private knowledge, should be shared with staff if the staff needs to know such information in order to support the volunteer or provide further assistance to the client. Volunteers should be honest with clients about the possible need to share limited information.

Knowledge about a person’s intent to harm him or herself or others or knowledge about the abuse or potential abuse of a vulnerable adult should be shared with staff so they may share with appropriate authorities.
When you need to talk about your volunteer experience, discuss your volunteer situation focusing on your experience rather than the client’s.

We are confident in your ability to follow this confidentiality practice and request your signature stating you will do your part to maintain this confidentiality and the privacy rights of the clients you are volunteering for.
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Full Name - First Name, Full Middle Name & Last Name *
First, full middle & last name
Maiden, Alias or Former Name(s) *
Please enter NA if not applicable
Date of Birth *
Include month, date & year
Email *
Sex *
Address Line One *
Address (City, State ZIP) *
Phone number *
List any & all Minors Names *
First and last name / Put NA if not applicable
I am interested in:
Volunteer Time Available (if known) in hours, weeks, etc: *
Volunteer Purpose/Goal/Assignment: *
How did you hear about NE Seniors for Better Living? *
E-Signature of Volunteer Applicant *
I have read and understand and agree on behalf of myself and any minor children/wards to be bound by the terms of this agreement. E-Sign full name below:
Date *
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