Help Give Back, Volunteer At the Hospital

Check one*

Mr.

Mrs.

Miss

Ms.

Name*

First Middle Last

Birth Date*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Education (Highest Level Completed)*

If employed, Name of Company and their Phone Number*

Position at work?*

May we contact you at work?*

Are you retired?*

Yes

Previous Work Experiences (if retired)

Previous and/or Current Volunteer Experiences*

Have you been terminated from volunteering?*

Yes

If Yes, please explain

Skills, Special Interests*

Community Affiliations (Social, Service)*

How did you become interested in our volunteer program?*

General Condition of Health?*

Do you have any physical limitation that would affect your volunteering? If yes, please explain.*

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Please provide a reference (Name, Relationship, Address, Phone Number)*

Please provide a 2nd reference (Name, Relationship, Address, Phone Number)*

May we have permission to check information and references?*

Yes

Availability for Volunteer Assignment

Length of Commitment (1 semester, 6 months, 1 year, indefinite, other)*

Do you have a specific assignment in mind? (refer to list at the bottom of this page)*

Please give a sentence or two explaining your reasons for seeking vounteer service.*

Do you speak a language fluently other than English?*

Yes

If yes, please list the languages

Please type your name to confirm your understanding and agreement to the following:

I have completed the above information to the best of my ability and understand that any falsification of the information provided above may prohibit my activities as a volunteer. I agree to inform Oaklawn Hospital Personnel office of any changes. If I am selected as an Oaklawn Hospital Auxiliary volunteer, I agree to abide by all the hospital rules, regulations and expectations. I understand that either party may cancel this relationship at any time.

Name*

First Last

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status.

Phone

This field is for validation purposes and should be left unchanged.

Volunteer at Oaklawn

Application for Volunteer Services

Please type your name to confirm your understanding and agreement to the following:

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status.