Volunteer Application

WELCOME

Welcome! Thank you for your interest in becoming a Volunteer Ombudsman. Volunteers play a vital role in protecting the rights, dignity, and quality of life for residents in long-term care facilities.

Before we get started, please note: Volunteers must be at least 18 years old and must drive their own vehicles for facility visits to participate in this program.

We can accept the application of someone who has worked in a Skilled Nursing, Assisted Living and/or Board & Care within the last year, but we cannot begin their certified Ombudsman training until after one year has passed since their last day working at such a facility.

Are you 18 years of age or older?

Yes
No

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

VOLUNTEER PROFILE INFORMATION

Do you speak any languages other than English?

Yes
No

Are you currently employed?

Yes
No

DRIVER INFORMATION

Our Ombudsman may be required to drive throughout Ventura County. A volunteer must maintain their own auto liability coverage at least equal to state-required minimums, which is why we ask for the following information about your license and car insurance:

Driver's License Number

State issued

Auto Insurance Provider

Liability Insurance Coverage Amount

Collision Insurance Coverage Amount

EXPERIENCE

Why do you want to volunteer?

Please tell us about your prior volunteer experience?

INFORMATION a Insurance

REFERENCES

Please share three personal and/or professional references

ACKNOWLEDGEMENT

Volunteer Acknowledgement

Volunteer Acknowledgement

Yes, I acknowledge the information I provided in this form is current and accurate.

Applicant Signature

Clear Signature

WELCOME

We are sorry, but you must be 18 years or older and must drive your own vehicle to become a Certified Ombudsman.

CONTACT INFORMATION

VOLUNTEER PROFILE INFORMATION

DRIVER INFORMATION

EXPERIENCE

REFERENCES

ACKNOWLEDGEMENT

Ventura County Ombudsman

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