Volunteer Application

825 Magnolia Ave.
Corona, CA. 92879
(951) 273-7320
FAX (951) 737-7026

VOLUNTEER APPLICATION

All information in this document is confidential.

Peppermint Ridge acknowledges that equal opportunity for all persons is a fundamental human value. Each volunteer applicant will be considered on the basis of individual ability and merit, without regard to race, color, age, religion, national origin, disability, sexual orientation, sex, or marital status.

Peppermint Ridge Has ZERO Tolerance for Abuse, Neglect and/or Exploitation.

Any staff or volunteer witnessing abuse, neglect and/or exploitation MUST:

STOP the abuse, neglect and/or exploitation.
PROTECT and PROVIDE support, including comfort and aid to the victim.
REMOVE the alleged abuser from all client contact IMMEDIATELY.
CALL the RN to assess the individual. (This will include a physical for the victim and other potential victims).
CALL the FM/Q/Administrator to inform and assist with covering the shift.
ASSESS and PROVIDE comfort, aid and/or support, continually while working with the individual.
REPORT and DOCUMENT to the appropriate entities.

All Peppermint Ridge Staff are MANDATED REPORTERS (Per W&I Code 15630). All suspected or known abuse must be reported to Licensing, the Regional Center and the Ombudsman.

Peppermint Ridge’s Standard Policy and Procedure on abuse, neglect, and/or exploitation (SPP #201), states that it is expected that all Peppermint Ridge staff assist in promoting an environment for the individuals in our care that ensures their physical and emotional well-being, is not endangered in any way, and that protection from harm measures are in place at all times. This includes being vigilant and constantly alert to any and all potential harm to the residents of Peppermint Ridge, and to immediately take action if suspected harm has occurred to someone.

The policy also includes the requirement of a clear understanding by all staff, and between staff and volunteers, of our ZERO TOLERANCE of abuse, and that there are consequences/penalties, including possible conviction of a misdemeanor resulting in time in county jail and/or a fine from $1,000 to $5,000 when a mandated reporter fails to promptly act and/or report suspected or alleged mistreatment, abuse or neglect.

By signing this form, you acknowledge that you have read SPP #201- Alleged Abuse, Neglect and/or Exploitation, and have assumed the responsibility of being fully informed about Peppermint Ridge’s Zero Tolerance Policy regarding Client Abuse, Neglect and Exploitation.

Peppermint Ridge

STATEMENT OF CONFIDENTIALITY OF CLIENTS

I have been properly informed that I must respect the rights of all Residents at Peppermint Ridge. I have also been informed of the manner and importance of confidentiality in my contact with these Residents.

I understand that in my position, I may have or be given, information of a confidential nature. I agree that I will not divulge this information to anyone and I understand that I must not discuss such information outside Peppermint Ridge.

I acknowledge and agree that if I do not fully comply with this rule during my volunteer activity that I may be subject to appropriate actions.

Today's Date: June 27, 2022

COVID 19 AWARENESS

As a Ridge volunteer, I agree to abide by the Center for Disease Control (CDC)'s recommendations for the prevention of the spread of COVID-19 and attest to having read the CDC's guidance at : https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html. I agree to abide by any COVID-19 distancing and other safety guidelines issued by the state.

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Participant's Name

First Name*

Last Name*

Phone*

First Participant's Date of Birth*

First Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

If you are volunteering for a position that requires driving, Peppermint Ridge requires a valid driver's license and proof of automobile insurance. Are you able to use your automobile if the volunteer position requires one?*

Yes

As a volunteer, I agree to provide a valid driver's license number and proof of automobile insurance. I agree to mail or deliver copies of these documents to [nonprofit], so that they can be filed with this application.

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

First Participant's Signature*

Type Signature

Draw Signature

Click to Sign

Second Participant's Name

First Name*

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Third Participant's Name

First Name*

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Fourth Participant's Name

First Name*

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Fifth Participant's Name

First Name*

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Sixth Participant's Name

First Name*

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Seventh Participant's Name

First Name*

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Eighth Participant's Name

First Name*

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Ninth Participant's Name

First Name*

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Tenth Participant's Name

First Name*

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Participant's Address

Address Line 1:*

Street address, P.O. box, company name, c/o

Address Line 2:

Apartment, suite, unit, building, floor, etc.

Country:*

City:*

State/Province:*

Zip/Postal:*

Parent or Guardian's Email Address

Email*

Confirm Email*

Check to receive information, news, and discounts by e-mail.

STATEMENT OF CONFIDENTIALITY CLIENT

Under the provisions of the Health Insurance Portability and Accountability Act (HIPPA), I have been properly informed that I must respect the rights of all Residents and Clients at Peppermint Ridge and have been informed of the importance of confidentially in my contact with these Residents.

I understand that in my volunteer position, I may have or be given, information of a confidential nature. I agree that I will not divulge this information to anyone and I understand that I must not discuss such information outside of Peppermint Ridge.

Volunteer Print Name *

Click to customize date box label

I give my consent for my child, named on page one of this application, to provide volunteer services to [nonprofit] I also give [nonprofit] my consent to obtain any emergency medical treatment necessary for the safety of my child.

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Information

Work Phone

Physical Limitations (Be specific; if none, write none)

DRIVING INFORMATION

Yes

I will immediately notify my volunteer supervisor if my driver's license is restricted, suspended, revoked, or expired.

Insurance Carrier

Policy #

Driver's License #

State of Issue

Expiration Date

Parent or Guardian's Signature*

Type Signature

Draw Signature

Click to Sign

Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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