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2. 

4. This enrollment application is for volunteers age 55 and above. Please complete all sections.

6. First Name*
7. Last Name*
9. Street Address*
11. Address Line 2
13. City
14. State
15. Zip Code
17. Phone*
18. Cell Phone
20. Email*

24. 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:

26. Emergency Contact - First Name*
27. Last Name*
28. Relationship*
29. Phone Number*
31. Beneficiary for FGP Supplemental Accident Insurance - First Name*
32. Last Name*
33. Relationship*
34. Phone Number*
36. Beneficiary Street Address*
38. Address Line 2
40. City
41. State / Province / Region
42. ZIP / Postal Code
43. Country

47. The following information will help the Foster Grandparent Program match you with a volunteer opportunity:

49. Past Employment*
51. Volunteer Experience*
53. Special Skills / Talents / Hobbies*
55. Language(s) spoken:*
57. Have you ever worked with children?*

    1. Yes
    2. No
59. Please list your preferences for days and hours of work*

    (Example: Monday through Friday, 8 to 12)

61. Special Accommodations

    Do you require any special accommodations or have physical or medical considerations that may impact a volunteer assignment?

63. How did you hear about the Foster Grandparent Program?*
67. Background Check

    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?

68. Background Check*

    1. Yes, I Consent
    2. No, I Do Not Consent
70. Have you ever been convicted of a criminal offense or misdemeanor:*

    1. Yes
    2. No

72. Please list two character references (not relatives), including their complete address and phone number:

74. Character Reference 1
76. First Name*
77. Last Name*
78. Phone Number*
80. Address*
82. Address Line 2
84. City
85. State / Province / Region
86. ZIP / Postal Code
87. Country
89. Character Reference 2
91. First Name*
92. Last Name*
93. Phone Number*
95. Address*
97. Address Line 2
99. City
100. State / Province / Region
101. ZIP / Postal Code
102. Country
106. Income Eligibility

     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.

108. Consent
     • I certify that the information furnished above is correct and understand that falsification of information may result in my being deemed ineligible to receive a stipend as a Foster Grandparent. I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001 of Title 18, U.S.C. I certify that I have never been convicted of a murder or a sex offense of any nature, and agree to immediately notify the Director of the Foster Grandparent Program of New Hanover County if I am convicted of any criminal statute.
     • I hereby state that I am 55 years of age or older and offer my services as a volunteer for the New Hanover County Foster Grandparent Program. I understand that I am not an employee of the FGP Project, New Hanover County, the volunteer station or the Federal Government.
     • I understand that in my capacity as an FGP volunteer I may come in contact with confidential information. I agree to protect this information to the best of my ability and not to disclose it during or after my service as a volunteer has ended.
     • I understand that if I use my personal automobile in my volunteer service, I will arrange to keep in effect automobile liability insurance equal or greater to the minimum requirements of the state of North Carolina. I will also keep in effect a valid North Carolina Driver's license.
     • As a FGP Volunteer I have a right to meaningful work at the assigned volunteer station. I understand that at the assigned station I must represent myself, the New Hanover County Senior Resource Center, The New Hanover County FGP and my volunteer station in a professional manner. I understand that by signing this enrollment document I agree to review the volunteer manual and agree to uphold my job assignment. I understand that my failure to observe and abide by these policies and procedures may result in disciplinary action, which may include dismissal, contract termination, and/or punishment by fine and/or imprisonment.
110. Consent Statements*

     1. By checking here I acknowledge that I have read and understand the above statements
112. Electronic Signature Agreement*

     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.

     1. I agree.
114. Electronic Signature*
116. Equal Employment Agency

     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.

118. Gender

     1. Male
     2. Female
     3. Nonbinary
119. Race / Ethnicity
120. Marital Status

     1. Single
     2. Married
     3. Divorced
     4. Widowed
122. Military Service

     1. Active
     2. Veteran
     3. None
123. Are any of your family members actively serving in the military?

     1. Yes
     2. No
127. Photo Release

     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.

129. First Name*
130. Last Name*
131. Email*
133. Photo Release Agreement*

     1. Consent
     2. Decline

     You may either consent to or decline to release your photo rights as described above.

135. Electronic Signature Agreement

     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.

     1. I agree.
137. Electronic Signature*
141. Confidentiality Agreement

     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:

     • With those specifically authorized by written consent of the citizen, or others authorized to give consent for the citizen;
     • When necessary to provide appropriate care (within our agency) except as described in GS 130A-143;
     • Pursuant to subpoena or court order.

     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 understand that I may have direct or indirect access to confidential individually identifiable personal information (IIPI) in the course of performing my work activities.
       • Note: IIPI is any information collected from an individual that is created or received by the NHCSRC and relates to past, present or future contact, beneficiary, or individually identifiable information. Protected personal information (PPI) is IIPI in any form: paper, oral or electronic, that personally identifies an individual.
     • I agree to protect the confidential nature of all IIPI to which I have access and will not divulge this information to unauthorized persons.
     • I understand that there are state and federal laws and regulations that ensure the confidentiality of an individual’s identifying personal information.
     • I understand that there are New Hanover County Senior Resource Center (NHCSRC) policies and procedures with which I am required to comply related to the protection of IIPI.
     • I understand that my failure to observe and abide by these policies and procedures may result in disciplinary action, which may include dismissal, contract termination, and/or punishment by fine and/or imprisonment.
     • I understand how I am expected to ensure the protection of IIPI. Should questions arise in the future about how to protect information to which I have access, I will immediately notify my supervisor and/or the NHCSRC Director.
     • I have been informed that this signed agreement will be retained on file for future reference.
143. Consent*

     1. I agree to this confidentiality agreement.
145. General Communication

     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.

147. General SMS Message Acknowledgment Release*

     1. Consent
     2. Decline

     You may either consent to or decline to allow SMS (text) messaging as described above.

149. Electronic Signature Agreement

     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.

     1. I agree.
151. Electronic Signature*

153. 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 Wells
     Foster Grandparent Program Coordinator
     Phone: 910-798-6408
     Email Vicki Wells

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155. 1. Receive an email copy of this form.
156. Email address

     This field is not part of the form submission.

157. Submit

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