VP Application

Volunteer Inquiry or Application

A red asterisk (*) denotes required fields. Questions? Email us at vol@eldercare.org.
Helpful Info Before you Start:

Young Volunteers:

SCES volunteers must be at least 18 years of age. The exception is that we welcome youth to volunteer with parental supervision for our nutrition delivery events. If you are under 18, please email Lindsey Smilack at vol@eldercare.org.

COVID-19 Vaccination Required:

All SCES volunteers are required to be vaccinated against COVID-19, and to have received a booster if eligible, including youth under 18.

CORI Background Check Required:

SCES conducts a Criminal Offender Record Information check of all volunteers age 18+. Our application includes a CORI form.

Serving Somerville and Cambridge, MA:

If you live outside our service area, the Massachusetts Money Management Program website provides a handy search tool for Aging Services Access Points (ASAPs), by town.

Friendly Visiting Applicants:

Please visit the website of our valued partner, FriendshipWorks: fw4elders.org

Looking for Help at Home?

Call and ask for our Aging Information Department: (617) 628-2601.

Visit our website to learn about services: https://eldercare.org
About You
Jotform
Salutation*
Name*

First NameMiddle NameLast Name
Suffix
Nickname
Your Current Address*

Street Address

Street Address Line 2

CityState

Zip or Postal CodeCountry
Mobile Phone Number*

Area CodePhone Number
Company
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Which Number is Primary?*
Personal Email
example@example.com
Work Email
example@example.com
Alternate Email
example@example.com
Which Email Address is Primary?*
Would you like to indicate your pronouns?
For example: she/her/hers, they/them/theirs, he/him/his
How did you find us? (select one)
If you selected "other," please specify:
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Reference Person 1

List the names and contact information of at least two references not related to you (no family members, please). Please include at least one professional contact.
REFERENCE 1 relationship:
Reference 1 Name*

First NameLast Name
Reference 1 Email*
example@example.com
Reference 1 Phone Number*

Area CodePhone Number
Reference Person 2

List the names and contact information of at least two references not related to you (no family members, please). Please include at least one professional contact.
REFERENCE 2 relationship:
Reference 2 Name*

First NameLast Name
Reference 2 Email*
example@example.com
Reference 2 Phone Number*

Area CodePhone Number
*A third reference person is required for Money Management applicants (only).*
Reference Person 3

Please include at least one professional contact (no family members, please).
REFERENCE 3 relationship:
Reference 3 Name

First NameLast Name
Reference 3 Email
example@example.com
Reference 3 Phone Number

Area CodePhone Number
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Conflict of Interest Agreement
Conflict of Interest Agreement for Prospective Volunteers

I certify that if I become a volunteer of Somerville-Cambridge Elder Services, my involvement with clients will not constitute a potential conflict of interest. I agree that I:
- will never use my knowledge of any client’s situation for my own benefit or financial gain, or that of my employer, associates, family, friends or acquaintances.
- will not make suggestions or recommendations to any client from which I, my employer, associates, family, friends or acquaintances may profit or benefit in any way.
- will not accept payment, loans, or gifts of money or property from any client, except non-cash personal gifts, the value of which shall not exceed $25 in any calendar year.
- will refrain from giving any client financial, health care, or property advice. ·
- will avoid any activity which would place me in a position of actual conflict of interest or the appearance of conflict of interest.
Please sign here:*

Clear
Help Us Comply with HIPAA and WISP

(Health Insurance Portability and Accountability Act and Written Information Security Program, respectively)
Client Confidentiality: SCES staff and volunteers follow federal “HIPAA” and Massachusetts’ “WISP” privacy laws, which means our clients’ information is confidential. Please safeguard their names, addresses, contact info, and health or finacial information. Please also refrain from photographing our consumers or using their likeness (we ask written permission to take photos).
I understand that client information is confidential.*

Yes
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CORI Form and Government-issued Identification

The CORI is a required criminal background check standard for all community-based volunteers. According to MA General Laws Chapter 6 Sec 167-178B, we are required to request a CORI of potential volunteers who would meet with clients.  The CORI consists of the next 2 pages. Questions? Email vol@eldercare.org
THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: (617) 660-4640/ TTY: (617) 660-4046/ FAX: (617) 660-5973

MASS.GOV/CJIS
Criminal Offender Record Information (CORI)

Acknowledgement Form

To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing purposes.

Somerville-Cambridge Elder Services, Inc is registered under the provisions of M.G.L c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.

As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to Somerville-Cambridge Elder Services, Inc. to submit a CORI check for my information to teh DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing Somerville-Cambridge Elder Services, Inc. with written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

Somerville-Cambridge Elder Services, Inc. may conduct subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that Somerville-Cambridge Elder Services, Inc., must first provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.

Signature of CORI Subject

Clear
Signature of CORI Subject

Clear
Date

MonthDayYear

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: (617) 660-4640/ TTY: (617) 660-4046/ FAX: (617) 660-5973

MASS.GOV/CJIS

SUBJECT INFORMATION

Please complete this section using the information of the person whose CORI you are requesting. The fields marked with an asterisk (*) are required fields.

Name*

First NameMiddle NameLast NameSuffix
Former last Name(s), separated by commas:
Date of Birth*

MonthDayYear
Place of Birth

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Last SIX digits of Social Security Number*
If no Social Security Number, put zeros
Sex:
Height
Eye Color
Race
Driver's License or ID Number
State of Issue

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Father's Full Name
Mother's Full Name
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Government-issued photo identification is required to run a CORI check!

Please supply one of the following: driver's license, state ID, passport, foreign passport with VISA, U.S. military ID.
Option 1: Take photo of photo ID
Option 2: Alternatively, please upload a PDF, PNG, or JPEG file of your photo ID:

Browse Files

Cancelof
Please sign to certify:

I understand that the references I have listed will be contacted and that the sponsoring agency will do a records check on qualified applicants. I consent to the release of all relevant information concerning my ability and fitness to volunteer. I certify that the information given herein is accurate to the best of my knowledge. I understand this information will be held in confidence and not released to another agency.
Sign below*

Clear
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Almost Done!
Is there anything else you'd like us to know?
Click "Submit" to finish.

If you completed the full application, you will next be directed to our online Volunteer COVID-19 Vaccine Card Form.
Should be Empty:

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning
Afternoon
Evening

Volunteer Inquiry or Application

About You

Volunteer Opportunities

Choose Your Own Adventure

Background

Emergency Contact

Demographics

Reference Person 1

Reference Person 2

Reference Person 3

Conflict of Interest Agreement

Help Us Comply with HIPAA and WISP

CORI Form and Government-issued Identification

Government-issued photo identification is required to run a CORI check!

Please sign to certify:

Almost Done!