Volunteer Application - blank

* Required Fields

Personal Information

* Last Name:	* First Name:    Initial:
Address:
City:	State: AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Zip:
* Daytime Phone:	Email:
Date of Birth:	mm/dd/yyyy

Assignment Interests

Please indicate the type of volunteer placement preferred.

Clerical Support Gift Shop Patient Care Areas

Information Desk Shuttle/Golf Cart Driver Crafts (baby hats, turbans, etc.)

Escort/Concierge Errand Room Other

If other, please describe the type of assignment desired:

Skills

Please indicate the skills you feel are strengths.

Computer Skills Administrative

Interpersonal Communication Fundraising/Event Planning

Customer Service Telephone Skills

If you have other skills and/or abilities that you believe to be beneficial to our organization, please explain:

Education/Employment Information

Please indicate the highest level completed.

High School:   1 2 3 4    Undergraduate:   1 2 3 4   Other - please specify: 

Please list your current/most recent place of employment.

Employer:      From:      To:  
Occupation/responsibilities:

References

Please provide up to three references.

Reference Name	Company	Phone #

Have you ever been convicted of, been released without imposition of sentence, or received pretrial diversion for any crime, excluding motor traffic tickets?   Yes No

If YES, describe all of these actions, including the nature of the criminal offense(s), the location and dates, and their disposition. Conviction of a crime is not an automatic bar for consideration for volunteer service.


Please list any previous volunteer experience:

Availability

Please check the shifts you are interested in volunteering.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Mornings
Afternoons
Evenings

Will you be available to begin volunteering immediately after you have completed orientation and TB testing?   Yes No
Are you willing to commit to a three to four hour shift once a week?   Yes No

Emergency Contact Information

Contact Name:
Relationship:	Phone Number:

I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief; and hereby grant permission to Kettering Health Network to verify said statements through a national criminal background check.

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