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 / Province / Region ZIP / Postal Code Country

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

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.