Volunteer Interest Form

PERSONAL INFORMATION

First Name: *

Last Name: *

Middle Initial:

Name to Appear on Badge: *

Address: *

City: *

State: *
---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zip: *

Phone Number: *

Email Address: *

Birthday: *
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 01020304050607080910111213141516171819202122232425262728293031

Age: *
18+16-17

Are you a year-round resident? *
YesNo

EDUCATION

Check all that apply: *
High SchoolCollegePost Graduate

Degree(s):

WORK STATUS

Select One: *
EmployedRetiredUnemployed

SKILLS / WORK EXPERIENCE

Interests: *
AccountingLeadershipComputerNursingCustomer ServiceTeachingPublic SpeakingOther

Have you ever committed, been convicted of, pled guilty to, or pled no lo contender to, a felony or a misdemeanor? NOTE: Conviction of a crime is not necessarily grounds for disqualification. *
NoYes

VOLUNTEER AVAILABILITY

Please indicate the days and times you are available to volunteer: *

What is appealing to you about volunteering in a healthcare setting? *

Any special talents or skills you have that you feel would benefit our organization? *

IN AN EMERGENCY, PLEASE NOTIFY

Name: *

Relationship: *

Address:

Home Phone:

Cell Phone: *

Physician Name: *

Physician Phone: *

HOW DID YOU HEAR ABOUT OUR PROGRAM?

Check all that apply: *
FriendPamphletBrochureBulletin BoardWebsiteOther

SERVICE AREA OPPORTUNITIES

Please check any that would interest you: *
Working with PatientsCommunity EventsReception/Customer ServiceAuxiliary (Retail/Reception/Fundraising)Prefer No Patient ContactBehind the Scenes (Administrative/Clerical)Medicare Assistance (SHIBA)Hospice (In-Person or Administrative)

I confirm that the information provided in this application is true in all respects, without any willful omissions. I understand that if this application is false in any way, I will be dismissed without notice regardless of when the false information is discovered.

I understand that completing this application does not guarantee me a volunteer position and that I still must undergo an in-person interview and background check before being considered for a volunteer position.

If I am selected as a volunteer, I

• agree to a six-month commitment with a minimum of one shift per month
• agree to complete the volunteer orientation and train until I am competent to perform the required duties
• agree to complete an annual education review and employee health screening, as well as any additional service-specific training that may be deemed necessary
• agree to comply with all the rules and regulations of Good Shepherd Health Care System and to uphold the bylaws of my volunteer organization
• understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties outside of my service guidelines
• agree to contact my volunteer supervisor as soon as possible to request volunteer or schedule changes

I have read and agree to the above requirements for volunteering with Good Shepherd Health Care System.