Volunteer Application

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Long-Term Care Ombudsman Volunteer Application

The Office of the Long-Term Care Ombudsman provides Certified Volunteer Ombudsman for Kansans living in nursing, assisted and home plus facilities. They serve as the voice of the resident, working to make the system responsive to their needs and wishes. To do that, they investigate the resident's concerns and then work with facility staff and/or others, as appropriate, until these concerns have been resolved. The services provided are free and confidential for the resident. Once trained, volunteers are asked to regularly visit residents in their assigned facility and helping to resolve issues. Thank you for your interest in becoming a volunteer Certified Ombudsman - we look forward to reviewing your application!

Contact Information

First Name

Last Name

Address

Address Line 2

City

State

Zip Code

Preferred Means of Contact

EmailTelephoneOther

Emergency contact name:

Preferred Phone Number

Contact's Relationship

contact's phone number

Applicant Information

Please describe any education, skills or experience that would help you preform the duties of an Ombudsman Volunteer

Work History

Please tell us about your work experience, including paid and volunteer positions.

If you are currently employed, please list your current job first. Use the remaining spaces to describe other work experiences (paid or volunteer). Or you may attach/upload your resume.

Upload Resume

Position #1

Employer/Organization

Job Duties

Position Title

Dates (year stated - year ended)

Role

Employee
Volunteer

Position #2

Employer/Organization

Job Duties

Position Title

Dates (year stated - year ended)

Role

Employee
Volunteer

Position #3

Employer/Organization

Job Duties

Position Title

Dates (year stated - year ended)

Role

Employee
Volunteer

References

Please provide two references not related to you and their contact information

Reference #1

First name, Last Name

How long known?

Phone Number

Relationship

Reference #2

First name, Last Name

How long known?

Phone Number

Relationship

Note: To ensure the safety of our clients, volunteers, and the communities we serve, applicants will be asked to consent to a criminal record check. We will ask you to complete a separate form of authorization.

Authorization and Certification
I certify that the information I provided in this application is true, complete, and accurate to the best of my knowledge. I authorize the Office of the Kansas Long-Term Care Ombudsman to contact the references named above with regard to my application to become an Ombudsman volunteer. I also authorize the persons referenced to provide information in connection with my application.

First Name, Last Name

Date

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