Ohio Department of Aging

Personal Information

Your Name (Last, First, M.I.):
Street Address:
City, State, Zip:
County: --Select One-- Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot

E-mail:

Home Phone (with area code):
Work Phone (optional):
Mobile Phone (optional):
Best time to call: --Select One-- Morning Afternoon

Emergency Contacts (Please provide the name and phone number of two individuals we may contact in case of emergency).

Emergency Contact 1:
Phone:

Emergency Contact 2:
Phone:

Current Employment (Please note: Current employment with a provider of long-term care services creates a conflict of interest and disqualifies you from service as an ombudsman Associate.)

Current Employer:
Current Job Title:

Education: (Please list any education you have had that would apply to your duties as an Ombudsman Volunteer)

Related Experience: (Please include activities in which you acted as an advocate or worked with the aging population.)

Other Volunteer Experience:

Related Skills: (Please list and any special skills you have, such as speaking a foreign language, computer proficiency, etc.)

Other Information

Have you ever been arrested or convicted of a crime other than a minor traffic violation: YES NO
If YES, please explain:

Do you have a valid driver's license and current insurance: YES NO

Training Availability (Please indicate your availability for training during the following times to aid your regional program in planning. Training may not be available at all times listed.)

Weekday Mornings --Select One-- Always Available Often Available Rarely Available Never Available
Weekday Afternoons --Select One-- Always Available Often Available Rarely Available Never Available
Weekday Evenings --Select One-- Always Available Often Available Rarely Available Never Available
Saturday Mornings --Select One-- Always Available Often Available Rarely Available Never Available
Saturday Afternoons --Select One-- Always Available Often Available Rarely Available Never Available

References: (Please list three persons not related to you whom we may contact as references):

Reference 1:
Address:
Phone:

Reference 2:
Address:
Phone:

Reference 3:
Address:
Phone:

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