VP Application

Volunteer Inquiry or Application

A red asterisk (*) denotes required fields. Questions? Email us at vol@eldercare.org.
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*
Home Phone Number
Work Phone Number
Which Number is Primary?*
Company
Jotform
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:
Group Opportunity

I am inquiring on behalf of a group

References

Please list two references (not related to you), one of whom is a professional contact.
REFERENCE 1 Name*

First NameLast Name
Reference 1 relationship:
Reference 1 Email*
example@example.com
Reference 1 Phone Number*
REFERENCE 2 Name*

First NameLast Name
Reference 2 relationship:
Reference 2 Email*
example@example.com
Reference 2 Phone Number*
The Money Management program requires a third reference (not related to you).
REFERENCE 3 Name

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

Agreements
Conflict of Interest Agreement

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.
Client Confidentiality Agreement

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
Please sign here:*

Clear

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 the 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
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
Mother's Full Name
Father's Full Name
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, or U.S. military ID.
Please upload a PDF, PNG, or JPEG file of your photo ID. Please do not use photos with Apple's proprietary HEIC format.

Browse Files

Cancelof

Almost Done!
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

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

Choose your own adventure!

Background

Emergency Contact Person

Demographics

References

Agreements

CORI Form and Government-issued Identification

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

Almost Done!

Please sign to certify: