LTCOP Volunteer Application

Section 1

Personal information

Contact details and Florida residency.

Full legal name *

Email *

Date of birth *

Cell phone

Home phone

Street address *

City *

State *

ZIP *

County *

Are you a Florida primary resident? *

Yes No

Do you have your own reliable transportation? *

Yes No

Section 2

Background

Help us understand your experience and skills.

Prior volunteer experience

Work experience

Employer

Position

Dates

Responsibilities

Education

School

Year

Degree / certificate

Special qualifications or skills

Other languages spoken

Section 3

Conflict of interest

A potential conflict does not automatically disqualify you — disclosure is what matters.

Examples include: you, your family, or a friend live in, work for, own, or have a financial interest in a long-term care facility in the state of Florida.

Do you have a potential conflict of interest? *

Yes No

Section 4

Availability

Indicate when you could typically visit facilities.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Section 5

Criminal history disclosure

A Level II background screening is required before certification. Disclosing here does not automatically disqualify you.

Have you ever been convicted of a crime, or are charges currently pending? *

Yes No

Section 6

Personal references

Two references who are not family members.

Reference 1

Name *

Address *

Phone *

Reference 2

Name *

Address *

Phone *

Section 7

Volunteer fit & demographics

Optional, but helps us match you with the right council and improve outreach.

Prior healthcare or eldercare experience

Populations you'd like to serve

Hours per week available

Travel radius (miles)

Gender

Ethnicity

Languages you speak

Accessibility needs we should know about

Why do you want to volunteer with LTCOP?

Long-term goals as a volunteer

Anything else you'd like us to know?

How did you hear about us? *

Section 8

Certification & signature

By signing, you certify the information above is accurate to the best of your knowledge.

I am requesting that my home address, telephone number, and photograph be exempt from public record per §119.07(3)(k)1, Florida Statutes.

Signature (typed) *

Date *

I certify that the information provided is true and accurate. I understand that providing false information may disqualify me from serving as a volunteer ombudsman, and I authorize the LTCOP to verify the information and conduct a Level II background screening. *

I have read and understand the Privacy Notice, including how my personal information will be collected, used, stored, and shared with LTCOP staff for the purpose of evaluating my volunteer application. *

Apply to Become a Volunteer Ombudsman

Personal information

Background

Conflict of interest

Availability

Criminal history disclosure

Personal references

Volunteer fit & demographics

Certification & signature