<p> The Philadelphia Center 2020 Centenary Blvd. Shreveport, LA 71104 (318) 222-6633 Volunteer Application</p><p>Personal Data (Please print)</p><p>Name: ______Birth date: ___/___/___</p><p>Address: ______Street City State Zip Telephone ______Day Evening Other Email address: ______</p><p>Social Security # ______Driver’s License # & State______</p><p>Have you ever been convicted of a crime? □ Yes □ No If yes, state offense, date & location ______</p><p>Interests & Availability What type(s) of volunteer service interests you? _____ Hospital/home visits _____HIV/AIDS Education _____Food Pantry _____ Fundraising _____ Office/clerical work _____ Answer phones _____ Prevention packets _____ Community outreach _____ Counseling _____ Public Relations _____ Computer systems List any specialized skills ______</p><p>Availability ~ Sun. Mon. Tues. Wed. Thurs. Fri. Sat. Morning □ □ □ □ □ □ □ Afternoon □ □ □ □ □ □ □ Evening □ □ □ □ □ □ □ Night □ □ □ □ □ □ □ Experience ~</p><p>Employment Experience ~ (list most recent first)</p><p>Organization Name ______Address ______Dates ______Reason for leaving ______Position(s) ______Responsibilities ______Supervisor’s name ______Telephone ______</p><p>Organization Name ______Address ______Dates ______Reason for leaving ______Position(s) ______Responsibilities ______Supervisor’s name ______Telephone ______</p><p>Organization Name ______Address ______Dates ______Reason for leaving ______Position(s) ______Responsibilities ______Supervisor’s name ______Telephone ______</p><p>Volunteer Experience~ Organization Name ______Address ______Dates ______Reason for leaving ______Position(s) ______Responsibilities ______Supervisor’s name ______Telephone ______</p><p>Organization Name ______Address ______Dates ______Reason for leaving ______Position(s) ______Responsibilities ______Supervisor’s name ______Telephone ______Education and Training ~ Educational Institution Highest Year Completed Degree/Credits ______</p><p>GED (General Equivalency Diploma)? □Yes □ No □ N/A</p><p>Other training and Certifications Completed Expires ______</p><p>Language Skills other than English ______</p><p>What organizations do you belong to? ______</p><p>How did you hear about the Philadelphia Center’s volunteer opportunities? </p><p>□ School □ Brochure □ Employer □ Center Volunteer □ Staff Member □ Media □ Other</p><p>Name, address, and phone numbers of two references who have known you for at least 2 years: ______</p><p>In case of emergency, please notify:</p><p>Name: ______Relationship to you: ______</p><p>Address: ______</p><p>Phone #: ______</p><p>Please read carefully and sign below. I understand that I am not to reveal the HIV 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.</p><p>Signature: ______date: ____/____/_____ Volunteer Waiver</p><p>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. </p><p>HEREINAFTER, ______will be known as a volunteer.</p><p>Therefore, this agreement is entered into by the volunteer with the Philadelphia Center to protect the confidentiality of the person or persons who are HIV infected or have any other disease-state that the volunteer may be able to identify.</p><p>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 paper work or access needed services.</p><p>Further, only volunteers who have consented to this agreement will have access to any record or parts of records.</p><p>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.</p><p>Further, should this confidentiality be breached the said volunteer will be immediately relieved of duties.</p><p>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.</p><p>Signed: Print Name: Date:</p><p>______</p><p>Witness: Print Name: Date:</p><p>______TAKING STEPS TO PREVENT INFECTION</p><p>Some ways to avoid passing from patient to caregiver:</p><p>The body fluids that transmit HIV are semen, vaginal fluids, blood and mother’s breast milk. You cannot contract HIV from saliva, urine or feces. However, these other fluids may contain germs that are transmitted through them.</p><p> Always avoid the exchange of all body fluids.</p><p> Don’t share toothbrushes, razors, towels or other items that might be contaminated with blood or other body fluids.</p><p> Wear latex gloves if there is a chance you will be exposed to blood or other body fluids.</p><p> If you should come into contact with any body fluids, you should wash the affected area with soap and water gently.</p><p>Some ways to avoid passing germs from caregiver to patient:</p><p>A person with HIV/AIDS has a difficult time fighting even a mild infection.</p><p> Cover your mouth when you cough or sneeze.  Wash your hands regularly.  Arrange for someone else to provide care if you have a cold, flu or any other illness that could be transmitted casually.</p><p>I have read the information and understand it fully. If I have a compromised immune system and/or HIV/AIDS, I will consider not being a hospital sitter or buddy to a client who is contagious. I also understand that should I pose a possible health risk to a client (i.e. communicable or infectious disease) I will not have any contact with said client.</p><p>______signature date</p>