Respite Care Application

Respite caregivers must be 18 years of age or older. If you are interested in becoming a respite caregiver at Palmer Home for Children, please fill out and submit the form below. NOTE: Mentors must complete trauma-informed training in order to become eligible to serve as a mentor.

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
- Add me to the Palmer Home email list.
Date of Birth*
Home Phone*
Please indicate which days and hours that you will be available to provide respite care.*
Total Hours Available Weekly*
Why do you want to become a caregiver at Palmer Home for Children?*
Have you ever been an employee/volunteer for Palmer Home for Children?*
- Yes
- No
Please indicate last date of employment/volunteer.
Date Format: MM slash DD slash YYYY
Previous Volunteer or Caregiver Experience
Church Affiliation
Pastor
First Last
Pastor's Phone
Present Employment*
Supervisor*
First Last
Supervisor's Phone*
Please provide one professional reference and two personal references. (ex: pastor, employer, neighbor, etc.) Be sure to include complete addresses and phone numbers.*
Have you ever been convicted of a crime?*
- No
- Yes
If applicable, please provide all details of each conviction, including dates and sentences imposed.
In case of emergency, please notify:*
First Last
Relationship*
Phone*
Special Need(s)
BACKGROUND CHECK RELEASE OF INFORMATION AUTHORIZATION
I hereby give my permission for Palmer Home for Children, P. O. Box 746, Columbus, MS 39703 to conduct a check of my general background, including criminal history. I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for some types of volunteer work. I hereby authorize, without reservation, any law enforcement agency, administration, state agency, institution or information service bureau to furnish any and all background information that it may have on file for me to Palmer Home or its designated agents. I further agree to release any party providing such information from any and all liability for damages of whatever kind to me, my family, heirs or associates that may arise as a result of giving such information or from my being granted or denied volunteer experience.
Signature (Please type your full name.)*
“Signing” above indicates that (1) You have read this application in its entirety and that you fully understand and comply with all terms and agreements herein, and have provided, to the best of your knowledge, complete and entirely accurate information. (2) You hereby release, absolve, indemnify, and hold harmless Palmer Home for Children, the organizer, sponsors, and supervisors from any and all loss or injury that may be incurred in connection with the filing of this application or the subsequent performance of volunteer duties. The requested record(s) shall be used for Palmer Home for Children business purposes only.
Date*
Date Format: MM slash DD slash YYYY
CAPTCHA

Events

Learn More

Impact Report

Download PDF

Learn More

Respite Care Application

Respite Care Application

BACKGROUND CHECK RELEASE OF INFORMATION AUTHORIZATION

Events

Impact Report

Newsletter

Contact Us

Choose your donation type

Stay updated