Angel Buddy Program

ANGEL BUDDY Program

Many of Holy Angels’ residents have wonderful family support. Unfortunately, some do not, whether their family has passed, is no longer involved in their lives, or is unable to visit them. Angel Buddies are volunteers or groups of volunteers who are paired with a Holy Angels resident who is in need of additional ongoing love, support, and empowerment.

Angel Buddies spend time with their Buddies and help them celebrate special occasions, such as birthdays, holidays, and events at Holy Angels.

If you or your group is interested in becoming an Angel Buddy, please fill out the application below.

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Angel Buddy Application

Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact
Name*
First Last
Phone*
Relationship*
Personal Information
Volunteer Experience:*
Community Affiliations:*
Are there any tasks that you may be unable to perform given any health condition that might limit or impact your ability to do so?*
Are you applying as an individual, or as a group? If group, please explain.*
Is there a particular resident you're interested in working with? If no, please type N/A.*
Personal References
Reference 1 Name*
First Last
Reference 1 Phone*
Reference 1 Relationship*
Reference 2 Name*
First Last
Reference 2 Phone*
Reference 2 Relationship*
Reference 3 Name*
First Last
Reference 3 Phone*
Reference 3 Relationship*
Work Schedule
Please List Availability*
How many hours do you want to volunteer?*
How often do you want to volunteer?*
Please list dates and times that work for your schedule:*
Confidentiality Statement
As a participant in the Volunteer Experience Program of Holy Angels, I understand that I have an obligation to safeguard all information to which I have access and I am prohibited from sharing confidential information with other volunteers, employees not directly involved with care of the resident, and/or outside of Holy Angels Residential Facility.

Maintaining confidentiality and security of information is critical to our commitment to the Core Values of Dignity and Integrity. We know it is the right thing to do. Since April 14, 2003, sharing confidential information about a resident with someone who does not need to know means we have also broken a Federal Law. The Health Insurance and Portability and Accountability Act (HIPAA) make sure that resident medical information is kept private and secure. A violation of HIPAA privacy rule carries heavy civil and criminal fines.

Confidential Information includes but is not limited to:
- Resident medical information
- Resident financial information
- Employee wages, salaries and other pay information
- Employee and Volunteer disciplinary actions/discussions
- Holy Angels financial or business development data
- Holy Angels Information Systems access codes and data
I understand that unauthorized disclosure of Holy Angels Residential Facility confidential information will result in my dismissal from the Volunteer Experience Program and may include legal ramifications for my actions.

I understand that either Holy Angels or myself reserves the right to end a volunteer’s relationship with the agency at any time.

I understand that any false, misleading, incorrect or incomplete answer made by me in this application will be considered sufficient cause for denial of volunteer position.
Do you agree to the above Confidentiality Agreement?*
- I agree.
- I do not agree.

ANGEL BUDDY PROGRAM

Angel Buddy Application

Emergency Contact

Personal Information

Personal References

Work Schedule

Confidentiality Statement

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