Volunteer Opportunity | LSS Better Together

Better Together Volunteer Application

To become a volunteer for LSS Better Together, please complete the fields listed below and click "Send Now" at the bottom of the page. If a couple, family or group are volunteering together, every person over the age of 18 must complete an application.

If you do not receive a confirmation email within 48 hours confirming the application went through successfully, please contact LSS Better Together at 605-444-7805.

Please also be sure to complete the release for a criminal background check. Both the application and release forms must be completed in order to apply to become a mentor.

Background Check Release Form

Contact Information

First Name

Last Name

Middle Initial

Gender (identifies as)

male
female

Home Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Home Phone

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Work Phone

Cell Phone

How would you like us to contact you?

Email
Text
Facebook
Cell
Work

Prefer call in

a.m.
p.m.

Employer Name

Job Title

Number of Years with Employer

Employer Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Have you ever been convicted of a drug charge?

If so, charge and year it occurred

Have you ever been convicted of a criminal offense?

If so, charge and year it occurred

Have you ever been convicted of abuse, neglect, or assault?

If so, charge and year it occurred

I am volunteering

on my own
with another person
with a group
with my family

List the person or group you are volunteering with. All volunteers aged18 and older must complete an application.

Volunteers under the age of 18 must be accompanied at all times by a parent or guardian who has completed an application when they volunteer. If you are volunteering with your child(ren), please list their names and ages:

I am comfortable working with a senior who lives alone.

I am comfortable working with a senior with limited mobility.

I am comfortable working with a senior on daily living tasks (grocery shopping, sorting mail, etc.)

I am comfortable going to community events with a senior.

I am comfortable transporting a senior in my personal car.

I am comfortable with a senior having a pet.

I am comfortable with a senior smoking or living with a smoker.

I am comfortable with a senior having limited room in their home or struggling to keep their home clean?

I am comfortable with a senior having some memory issues.

I am comfortable with a senior dealing with a chronic condition.

Referral Information

How did you hear about LSS Better Together? Check as many as apply and describe below

Please provide any additional referral details

Matching Information

I am available the following days/times:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

I would like to meet:

once per week
every other week
once per month
twice per month
other

Please define the other times you would like to meet:

I am interested in participating in monthly events organized by LSS?

yes
no
on occasion
not sure

Please list any other information about yourself you feel would be helpful in matching you. This can include any special hobbies, talents, or interests.

Please describe any previous experience working with older adults.

Why are you interested in volunteering for this program?

References

Please list three non-family references. Please provide complete information to expedite your application.

1st Reference

Name

Relationship

Primary Phone

Secondary Phone

Primary Email Address

Secondary Email Address

2nd Reference

Name

Relationship

Primary Phone

Secondary Phone

Primary Email Address

Secondary Email Address

3rd Reference

Name

Relationship

Primary Phone

Secondary Phone

Primary Email Address

Secondary Email Address

Emergency contact name

Relationship

Phone

Volunteer Agreement

Please check yes or no to confirm your understanding of the program guidelines. Thank you for carefully reading before completing.

By checking yes, I hereby state that if accepted as a mentor, I agree to abide by the rules and regulations of LSS Mentoring Services. I affirm that:

The information I have provided in the application may be verified, and I give permission to Lutheran Social Services of South Dakota to make inquiry of others concerning my suitability to act as a volunteer.

In the course of volunteering as a mentor, I may be dealing with confidential information, and I agree to keep said information in the strictest confidence. This means that I will not discuss my senior’s personal problems publicly or with others. If I need help, I will seek the assistance of LSS. I understand that this confidentiality does not apply to suspicions I may have about abuse, neglect, illegal activity, or suicide. If these issues arise, I will immediately contact program personnel.

The relationship between volunteers is an “at will” arrangement, and that it may be terminated at any time without cause by the volunteer, the senior, or Lutheran Social Services.

I agree to attend orientation.

I agree to abide by the policies and guidelines of the program. I understand that failure to do so may result in termination of the mentoring relationship.

I understand that all activities shall take place only during mutually agreed upon times.

I will volunteer approximately four hours per month. In the event that I cannot attend as scheduled, I agree to contact my senior in advance of the scheduled meeting.

I am willing to commit to one year in the program and will be asked to renew my participation in subsequent years.

I understand that I will be able to meet in public locations throughout the community.

I will participate in an additional training, submit to additional background screening (fingerprinting, auto insurance, etc).

I agree that my assignees, heirs, distributes, guardians and other legal representatives will not make a claim against, or sue for injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, or volunteer contractor of the organization as a result of my participation as a volunteer. I hereby release LSS from all actions, claims, or demands that I, my assignees, heirs, guardians and legal representatives now have or may hereafter have for injury resulting from my participation as a volunteer.

If my volunteer service includes driving an automobile, I acknowledge that I have both a valid driver’s license and automobile liability insurance policy as required by state law. I agree to maintain my license and insurance in good standing for my entire tenure as a volunteer for the organization. I am knowledgeable of and agree to abide by local and state traffic laws. I agree not to drive while under the influence of alcohol and/or other intoxicating substances.

By clicking here, I certify that all the information I have provided in the application above is accurate.

Current Date

Administration

Better Together Volunteer

Better Together Volunteer Application

Contact Information

Referral Information

Matching Information

References

Volunteer Agreement

Administration