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Volunteers

The Philadelphia Center

2020 Centenary Blvd.  Shreveport, LA 71104

(318) 222-6633

 

Volunteer Application: 

Please fill out the application as completely as possible, If a question doesn’t pertain to you leave it blank. Once you have completed the application either drop it by the center or email it to Hershey Krippendorf, hkrippendorf@philadelphiacenter.org

Personal Data (Please print)

 

Name: ______________________________________________ Birth date: ___/___/___

 

Address: ________________________________________________________________

Street                                       City                                                          State                         Zip

 

Telephone _______________________________________________________________

Day                                          Evening                                                   Other

 

Email address: ___________________________________________________________

 

Social Security # _____________________ Driver’s License # & State______________

 

Have you ever been convicted of a crime?     □  Yes             □  No

If yes, state offense, date & location ____________________________________

 

 

Interests & Availability

What type(s) of volunteer service interests you?

 

_____ Hospital/home visits     _____HIV/AIDS Education  _____ Answer phones

_____ Fundraising                  _____ Office/clerical work     _____ Prevention _____Community outreach            _____ Counseling

_____ Public Relations

 

List any specialized skills __________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

Availability ~

Mon.    Tues.    Wed.   Thurs.    Fri.

Morning                        □          □         □          □          □

Afternoon                      □          □         □          □          □

Evening                          □          □         □          □          □

Night                              □          □         □          □          □

 


Experience ~

 

Employment Experience ~ (list most recent first)

 

Organization Name _______________________________________________________

Address ________________________________________________________________

Dates ____________________ Reason for leaving ______________________________

Position(s) ________________________ Responsibilities ________________________

________________________________________________________________________

Supervisor’s name ___________________________ Telephone ____________________

 

 

Organization Name _______________________________________________________

Address ________________________________________________________________

Dates ____________________ Reason for leaving ______________________________

Position(s) ________________________ Responsibilities ________________________

________________________________________________________________________

Supervisor’s name ___________________________ Telephone ____________________

 

 

Organization Name _______________________________________________________

Address ________________________________________________________________

Dates ____________________ Reason for leaving ______________________________

Position(s) ________________________ Responsibilities ________________________

________________________________________________________________________

Supervisor’s name ___________________________ Telephone ____________________

 

 

 

Volunteer Experience~

Organization Name _______________________________________________________

Address ________________________________________________________________

Dates ____________________ Reason for leaving ______________________________

Position(s) ________________________ Responsibilities ________________________

________________________________________________________________________

Supervisor’s name ___________________________ Telephone ____________________

 

 

Organization Name _______________________________________________________

Address ________________________________________________________________

Dates ____________________ Reason for leaving ______________________________

Position(s) ________________________ Responsibilities ________________________

________________________________________________________________________

Supervisor’s name ___________________________ Telephone ____________________

 


Education and Training ~

Educational Institution                       Highest Year Completed        Degree/Credits

_____________________________  _______________________  __________________

_____________________________  _______________________  __________________

_____________________________  _______________________  __________________

 

GED (General Equivalency Diploma)?          □Yes               □ No                □ N/A

 

Other training and Certifications        Completed                              Expires

_____________________________  _______________________  __________________

_____________________________  _______________________  __________________

_____________________________  _______________________  __________________

 

Language Skills other than English ___________________________________________

 

What organizations do you belong to? _________________________________________

________________________________________________________________________

________________________________________________________________________

 

How did you hear about the Philadelphia Center’s volunteer opportunities?

 

□  School                     □  Brochure                 □  Employer                □  Center Volunteer

□  Staff Member         □  Media                     □  Other

 

Name, address, and phone numbers of two references who have known you for at least 2 years:

________________________________                    ______________________________

________________________________                    ______________________________

________________________________                    ______________________________

________________________________                    ______________________________

 

In case of emergency, please notify:

 

Name: _____________________________________ Relationship to you: ___________

 

Address: ________________________________________________________________

 

Phone #: ________________________________

 

Please read carefully and sign below.

 

I understand that I am not to reveal the HIV/STI status of any individual made known to me through association with the Philadelphia Center.  I will sign a statement of confidentiality before beginning any volunteer work.

 

Signature: ____________________________________________ date: ____/____/_____

 

Volunteer Waiver

 

Whereas the Philadelphia Center has need to use volunteers in the program(s) developed by the Volunteer Coordinator, and whereas volunteers can provide these services, an agreement on confidentiality must be executed before the volunteer may participate in this project.

 

HEREINAFTER, _________________________________ will be known as a volunteer.

 

Therefore, this agreement is entered into by the volunteer with the Philadelphia Center to protect the confidentiality of the person or persons who are living with HIV or have any other health issue that the volunteer may be able to identify.

Further, all records that are kept relating to persons will be kept in a locked filing cabinet: only those who need to will be allowed to access such records.  “Need to Know” is defined as those persons who give direct care, those who may be at risk of infection unless they are aware of the person’s diagnosis, and would be able to take correct precautions for their own safety or those who fill out paperwork or access needed services.

Further, only volunteers who have consented to this agreement will have access to any record or parts of records.

Further, a volunteer who comes in contact with information that must be kept confidential, including – but not limited to – name, disease state, sexual preference or other information that could compromise the person will be bound under this agreement to keep all information confidential.

Further, should this confidentiality be breached the said volunteer will be immediately relieved of duties.

Included in this obligation is a copy of a current Driver’s License or State issued identification, in addition to a copy of valid auto insurance for those who may drive.  These are to be copied and kept on file as long as the volunteer offers services to the Philadelphia Center.

 

Signed:                                                            Print Name:                             Date:

 

__________________________________    _______________________  ____________

 

Witness:                                                          Print Name:                             Date:

 

__________________________________    _______________________  ____________

 

 

 


How is HIV Transmitted

 

Got the Facts?

 

By having unprotected sex with

someone living with HIV

 

By sharing a syringe with someone

living with HIV

 

From an HIV+ mother to baby

before, during birth or afterwards

via breast milk

 

HIV is transmitted through blood,

semen, vaginal fluids, and

breast milk only!

 

HIV is NOT transmitted

 

Donating blood

Touching, hand-holding, hugging

Sharing a bathroom or toilet

Coughing, saliva, sweat, sneezing

Eating after a person with HIV

Sharing utensils

Swimming pools

Sharing clothes, towels, or bedding

Mosquito or other insect bites

 

__________________________________________________        __________________

signature                                                                                              date