This enrollment application is for volunteers age 55 and above. Please complete all sections.
As a Foster Grandparent (FGP) volunteer, you will be covered by accident and personal liability insurance plus a small death benefit while performing volunteer duties. This coverage is automatic and at no cost to you as long as you are an active, enrolled member of New Hanover County’s Foster Grandparent Program. Please provide the following information:
The following information will help the Foster Grandparent Program match you with a volunteer opportunity:
(Example: Monday through Friday, 8 to 12)
Do you require any special accommodations or have physical or medical considerations that may impact a volunteer assignment?
All applicants must undergo criminal background checks before placement. Persons with convictions of murder or records of sexual offenses will not be allowed to serve in the Foster Grandparent Program. Other prior arrests will not automatically preclude enrollment, based on the discretion of AmeriCorps Seniors staff. Do you consent to the Foster Grandparent Program staff arranging for a criminal history check in accordance with the Federal requirements for the Foster Grandparent Program?
Please list two character references (not relatives), including their complete address and phone number:
In order to receive a stipend, a Foster Grandparent cannot have an annual income from all sources, after deducting allowable medical expenses, which exceeds the program’s income eligibility guideline for the state in which he or she resides. Annual income is required to be counted for the past 12 months for serving volunteers and is projected for the next 12 months for new applicants. During your initial meeting with FGP Program Staff, eligibility guidelines will be discussed.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
New Hanover County FGP is an equal opportunity Agency. Enrollment is done without regard to race, color, national origin, gender, sexual orientation, religion, age, disability, political affiliation, marital or parental status, or military service. AmeriCorps Seniors FGP provides reasonable accommodations to the known disabilities of individuals in compliance with the Americans with Disabilities Act. For accommodation information or if you need special accommodations to complete the application process, please contact New Hanover County FGP at 910-798-6408.
The following information is optional and will not affect your enrollment with Foster Grandparent Program in New Hanover County.
I hereby authorize New Hanover County Senior Resource Center hereafter referred to as NHCSRC, to publish photographs taken of me, as well as my name and likeness, for use in the NHCSRC’s print, online and video-based marketing materials, as well as other Company publications.
I hereby release and hold harmless NHCSRC from any reasonable expectation of privacy or confidentiality associated with the images specified above.
I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.
I hereby release NHCSRC, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.
You may either consent to or decline to release your photo rights as described above.
The New Hanover County Senior Resource Center policy regarding confidentiality of citizen information is in accordance with laws which specifically address confidentiality (GS 130A-12, GS 130A-143, GS130A-212). All information concerning citizens is strictly confidential and should only be discussed or shared:
Failure to observe the policy regarding confidentiality is reason for suspension or dismissal and may subject the employee, student, volunteer or contract worker to a lawsuit. All employees, students, volunteers, and contract workers will be required to sign a statement of understanding regarding this policy.
I hereby authorize New Hanover County Senior Resource Center hereafter referred to as NHCSRC, to contact me at the phone number(s) provided via SMS (text) message and communicate with me regarding volunteer duties, responsibilities, scheduling, and availability. I hereby release and hold harmless NHCSRC from any expectation of privacy or confidentiality associated with this communication. I understand that I can opt out from receiving text messages by texting ‘STOP’ as a reply. I further acknowledge normal cellular data and messaging rates may apply. The number of SMS (text) messages received will be limited and will generally not exceed more than 5 messages a month.
You may either consent to or decline to allow SMS (text) messaging as described above.
Thank you for the information you have provided. Your information is never sold, shared, or used outside of FGP and New Hanover County.
For questions contact:
Vicki WellsFoster Grandparent Program CoordinatorPhone: 910-798-6408Email Vicki Wells
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