Volunteer Packet

Phone Number: 773-274-4227

Mailing Address: 6339 N. Fairfield, Chicago, IL 60659
Email Address: mary.zeien@thewellofmercy.com
Dear Potential Volunteer:

I would like to thank you for your interest in becoming a volunteer with the Well of Mercy. This program
was created to support single pregnant women who courageously choose life for their unborn children.
Through the dedicated work of staff and volunteers, the Well of Mercy offers pregnant mothers shelter,
education, emotional support and spiritual guidance to build a poverty-free future for their families.

There are many volunteer opportunities available through the Well of Mercy and we ask that volunteers
make at least a 6 month commitment, in order to maintain an environment of continuity and trust. Along
with filling out an application, signing the confidentiality agreement, and having a recent Tuberculosis
test, volunteers over 18 are required to have a background check.

This packet includes all of the necessary information about becoming a volunteer with the Well of Mercy.
After you complete the packet, please return it to 6339 N. Fairfield, Chicago, IL 60659 or by email to
Mary Zeien at mary.zeien@thewellofmercy.com . If you have any questions, please contact the office at
(773) 274-4227.

We look forward to you joining our team and becoming better acquainted with the Well of Mercy, the
women and children we serve, and the many needs that face our community

Sincerely,

Mary Zeien, LCSW

Executive Director

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 VOLUNTEER APPLICATION CHECKLIST

 Fill out Volunteer Application

 Read & Sign Volunteer Code of Conduct
 Read & Sign Confidentiality Agreement
 Read & Sign Volunteer Release Form
 Read & Sign Driver Agreement (if applicable)

Within three months of when you start volunteering, please submit:

 Proof of Tuberculosis test

 Proof of Child Protection Training
 Have a professional, academic, or religious reference fill out the Reference
Form

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 VOLUNTEER OPPORTUNITIES

Volunteers are needed in the following areas:

Administrative Support
 Office Work
 Thank you notes and donation receipts

Mentor
 In-tact family mentor program
 Individual mentor
Domestic Skills
 Cooking
 Sewing, knitting, crocheting
Teacher/Facilitator
 Tutor
 Baby care-birthing classes, lactation, nursing
 Bible Study
 Teach a class
 Share your testimony
Special Events
 Special Celebrations (baby showers, graduation ceremonies, tea parties)
 Tickets to events for residents
 Special activities/group outings
Donations Volunteer
 Sort and organize donations
 Calling for donation support
 Assist in organizing fund-raisers
House Support
 Pray partner
 Minor repairs/house maintenance
 Baby cuddlers

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
  Drivers to transport Clients

WELL OF MERCY VOLUNTEER APPLICATION

Name_____________________________________________ Date________________

Address______________________________________________________________________

City_____________________________________State_________________Zip____________
Work Phone ( ) ______________________ May we call you at work? Yes No
Home Phone ( ) ______________________ Cell ( ) ________________________
E-mail Address________________________________________________________________
Employer: ___________________________ Occupation: ______________________________

Are you presently enrolled in school? Yes No

High School: _____________________________________________
College: _________________________________________________
Do you speak another/secondary language? English French Spanish
Other: _____________________________

Availability

What qualities (skills, talents, knowledge and experience) do you feel you can incorporate into
your volunteer work? ___________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

What volunteer position/tasks are you interested in doing at the Well of Mercy?
---------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
--------

Please mark the days/hours you available to volunteer.

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 Monday Tuesday Wednesday Thursday Friday Saturday Sunday

From:
To:

Emergency Contact
Name: Relationship: ___________________________________
Phone Number #1: Phone Number #2:

Personal
An essential part of the Well of Mercy’s work is addressing the spiritual needs as well as the
physical, emotional, and educational needs of the women we work with. The Well of Mercy
works with women from diverse faith backgrounds.
Describe your faith experience: ____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What particularly interests you about the Well of Mercy? ______________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What gifts/strengths will you bring to the Well of Mercy? _____________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What are your weaknesses? ______________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
What do you like to do in your free time? ___________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

VOLUNTEER CODE OF CONDUCT

I understand that the Well of Mercy volunteers are considered employees for purposes of
compliance with standards and regulations. As such, I will follow the policies and
procedures provided to me by the Well of Mercy.
I agree to:
1. Attend and complete any and all volunteer orientation and training program offered by
the Well of Mercy prior to volunteering.
2. Volunteer for at least 6 months of service or until my services are no longer required

3. Adhere to the Mercy Home Policies including a smoke-free, alcohol free, and drug free
zone.

3. Adhere to a proper dress code that is appropriate for direct service including modest
dress and wearing a name badge if one is available

4. Notify the Volunteer Coordinator and not come to volunteer if I have cold/flu
symptoms, open-draining sores, nausea, or vomiting.

5. Maintain a safe working environment by following practice of work place safety and
infection control.

6. Communicate all concerns, incidents, misconduct, and complaints to the Volunteer

Coordinator.

7. Treat all clients with compassion, respect and dignity, regardless of their age, culture,
religion, political stance, or circumstance.

8. Transport clients only IF you have filled out the Volunteer Driver Agreement and
provided a copy of valid car insurance.

9. Speak to Well of Mercy administration before giving money or anything of value to

clients or staff

Volunteer Signature: _____________________________ Date: _________________

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 VOLUNTEER CONFIDENTIALITY AGREEMENT

I recognize that the services the Well of Mercy provides for women and their children are
confidential. While volunteering with the Well of Mercy, I agree that, except as directed
by the facility, I will not at any time during or after my volunteer time disclose any
information that I may overhear or be exposed to, to any person whatsoever. Protecting
confidentiality is primary to the operation of the Well of Mercy.
1. There may be times, that a child, individual or family may share information
with you that is personal and confidential. Your relationship with the child,
individual or family, their situation, and their personal affairs are privileged and
confidential information.
2. Only talk in generalities about the child, individual or family. Do not talk about
their personal lives, names, history, etc.
3. We want volunteers to talk about the program, benefits, your pride in your
service, but do not talk about specific persons, their homes, their problems, etc.
I agree to follow the above Rules of Confidentiality. I understand failure to do so will
result in immediate dismissal as a volunteer and possible legal ramification by the family
or the Well of Mercy.

Signature

Print Name

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
Date

VOLUNTEER RELEASE FORM

Release from Liability

I agree that my participation as a volunteer for the Well of Mercy is voluntary and that
my participation is at my own risk. I understand that my volunteer participation is not
employment by the Well of Mercy, and therefore is not covered by insurance. Further, I
release, discharge, and hold harmless all other persons from any and all liabilities or
claims that may result from my participation in volunteer activities for the Well of Mercy
and from any and all claims, losses or liabilities that I might experience or incur related to
my participation in the volunteer activities.

Name of Volunteer_________________________________
Signature: ________________________________________Date: _________________
Guardian Signature (for Minors only): _________________________ Date: _________
Photo Release
I authorize the Well of Mercy and its partners to copyright, publish, use, sell or assign all
photographic pictures, videotapes and/or sound recordings, or any part thereof, they have
take or made of me in connection with my volunteer participation, for publicity,
advertising or any other lawful purpose, in conjunction with my own or a fictitious name,
or in reproductions in any format. I hereby waive any claims for compensation for such
use or for damages.

Name of Volunteer_________________________________
Signature: ________________________________________ Date: _________________

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
Guardian Signature (for Minors only): ________________________ Date: __________

Non-Photo Release

I do not give permission for the Well of Mercy or its partners to use my personal photos.

Name of Volunteer_________________________________
Signature: ________________________________________ Date: _________________

VOLUNTEER DRIVER AGREEMENT

I _____________________ do hereby state that the following statements are true:

1. I have a valid Illinois driver’s license which has not been suspended or revoked during
the past five years
2. I understand that as a volunteer driver, my insurance is primary. I have in full force
and effect automobile liability insurance and do carry with me at all times proof of such
insurance
3. I have not been convicted of or pleaded guilty to driving under the influence of
alcohol, driving while ability impaired, or reckless driving during the past five years
I ___________________voluntarily accept responsibility to provide transportation, and, I
accept responsibility for the safety of my passengers and, at all times, I agree to:
1. Use and insist that all passengers use seat belts;
2. Drive carefully within established speed limits and driving conditions;
3. Keep my vehicle in safe operating condition;
4. Never drink any alcoholic beverages or take any drug which may inhibit my driving
ability with eight (8) hours before transporting any passengers; and
5. Obey all traffic laws

Signature

Print Name
773-274-4227
6339 N. Fairfield, Chicago, IL 60659
Date

Ask staff to make a copy of your car insurance & driver’s license
Attach both copies to this form

TB TEST FORM
We need to have a copy of the results of your tuberculosis (TB) skin test on file. Please
submit this within three (3) months of when you start volunteering. Reports of TB skin
test or chest x-rays from private physicians or health facilities are acceptable if taken
within the past 2 years. Please attach a copy of the results to this form.

Some locations that offer TB tests are listed below. If you have a primary physician they
might also offer TB testing. Have your medical provider fill out the TB Report below.

TUBERCULOSIS EXAMINATION REPORT

Volunteer’s Name: ___________________________________ Phone: ________________________

Volunteer’s Signature: ____________________________________

TB Test Date: _________________________________________

Results: _________________________________

Technician Signature: ______________________________________

Attention Medical Provider: Please affix clinic stamp in the box below or attach copy of test results to
this form. Thank you!

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 VERIFICATION OF CHILD PROTECTION TRAINING

All volunteers over the age of 18 are required to complete anIllinois Mandated Reporter
OR Virtus training within the first three (3) months of volunteering.

If you choose to do the Illinois Mandated Reporter Training:

1. Go to https://mr.dcfstraining.org/UserAuth/Login!loginPage.action
2. Register for an account.
3. Complete all sections of the training.
4. When you complete the training, please submit your certificate to the Volunteer
Coordinator at Jamila@thewellofmercy.com

You may register online and attend an in-person “Protecting God’s Children for Adults”
training session.

1. Go to www.virtus.org .
2. Click on “Registration.”
3. You can register and select an in-person training to attend. The training is 3 hours
long and is offered regularly at various locations throughout the Chicagoland area.
4. When you complete the training, please submit your certificate to the Volunteer
Coordinator at Jamila@thewellofmercy.com.

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
 CONFIDENTIAL VOLUNTEER REFERENCE FORM

To the Volunteer Applicant: You must provide us with a completed reference form from a professional,
academic or religious reference within the first three (3) months of volunteering. Family members may
not serve as references.

To the Reference: The person named below is applying to volunteer with the Well of Mercy, a home for
single pregnant women and their children. Please complete this form and return it to the volunteer
applicant in a sealed envelope. All information received will be held confidential by the Well of Mercy
Staff. Please contact us if you have any questions or concerns at (773) 274-4227.

Applicant’s Name: ____________________________________ Date: ___________________

How do you know the candidate? __________________________________________________

How long have you known the candidate? ___________________________________________

Please evaluate the applicant in the following areas using the scale below:

Poor Excellent

Dependability 1 2 3 4 5

Flexibility 1 2 3 4 5

Ability to work as a team 1 2 3 4 5

Communication Skills 1 2 3 4 5

Honesty 1 2 3 4 5

Enthusiasm 1 2 3 4 5

Initiative 1 2 3 4 5

What would be your overall recommendation for this applicant?

_____ My highest recommendation
_____ I recommend
_____ I recommend with reservations (please provide reason below)
_____ I cannot recommend this person to your program (please provide reason below)

Reason:______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Your name: ___________________________________ Phone Number: _________________________

Email Address: __________________________________

773-274-4227
6339 N. Fairfield, Chicago, IL 60659
Signature: _____________________________________________ Date: ________________________

773-274-4227
6339 N. Fairfield, Chicago, IL 60659