Better Together Volunteer

Gender (identifies as)

Have you ever been convicted of a drug charge?

Have you ever been convicted of a criminal offense?

Have you ever been convicted of abuse, neglect, or assault?

I am comfortable working with a senior who lives alone.

I am comfortable working with a senior with limited mobility.

I am comfortable working with a senior on daily living tasks (grocery shopping, sorting mail, etc.)

I am comfortable going to community events with a senior.

I am comfortable transporting a senior in my personal car.

I am comfortable with a senior having a pet.

I am comfortable with a senior smoking or living with a smoker.

I am comfortable with a senior having limited room in their home or struggling to keep their home clean?

I am comfortable with a senior having some memory issues.

I am comfortable with a senior dealing with a chronic condition.

The information I have provided in the application may be verified, and I give permission to Lutheran Social Services of South Dakota to make inquiry of others concerning my suitability to act as a volunteer.

In the course of volunteering as a mentor, I may be dealing with confidential information, and I agree to keep said information in the strictest confidence. This means that I will not discuss my senior’s personal problems publicly or with others. If I need help, I will seek the assistance of LSS. I understand that this confidentiality does not apply to suspicions I may have about abuse, neglect, illegal activity, or suicide. If these issues arise, I will immediately contact program personnel.

The relationship between volunteers is an “at will” arrangement, and that it may be terminated at any time without cause by the volunteer, the senior, or Lutheran Social Services.

I agree to attend orientation.

I agree to abide by the policies and guidelines of the program. I understand that failure to do so may result in termination of the mentoring relationship.

I understand that all activities shall take place only during mutually agreed upon times.

I will volunteer approximately four hours per month. In the event that I cannot attend as scheduled, I agree to contact my senior in advance of the scheduled meeting.

I am willing to commit to one year in the program and will be asked to renew my participation in subsequent years.

I understand that I will be able to meet in public locations throughout the community.

I will participate in an additional training, submit to additional background screening (fingerprinting, auto insurance, etc).

I agree that my assignees, heirs, distributes, guardians and other legal representatives will not make a claim against, or sue for injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, or volunteer contractor of the organization as a result of my participation as a volunteer. I hereby release LSS from all actions, claims, or demands that I, my assignees, heirs, guardians and legal representatives now have or may hereafter have for injury resulting from my participation as a volunteer.

If my volunteer service includes driving an automobile, I acknowledge that I have both a valid driver’s license and automobile liability insurance policy as required by state law. I agree to maintain my license and insurance in good standing for my entire tenure as a volunteer for the organization. I am knowledgeable of and agree to abide by local and state traffic laws. I agree not to drive while under the influence of alcohol and/or other intoxicating substances.