Adult Volunteer Application

Licensor / Certifications / Special Training
Please list any special training you have received, or any specialty areas for which you are currently certified/ licensed. Please include any state or national medical or health care related license (i.e. RN, LPN, LSW, etc.)
Licesne / Certification Number Expiration Date
Professional Memberships
You may exclude those which, the name of which, would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status.
Employment and/or Volunteer History
Dates Company / Address / Telephone Position / Job Duties Supervisor's Name

Account for all employment, including present job and periods of unemployment. Please include any military experience or job-related volunteer work. Start with current or most recent employment.
May we contact your current employer?*
- Yes
- No
Are you physically and mentally able to perform the job for which you have applied?*
*This hospital has a policy of non-discrimination with respect to volunteer services for individuals with disabilities. Information as to any handicap or disability obtained as a result of the foregoing inquiries will be kept confidential except as permitted or required by applicable law or regulation. Medical condition information is obtained for the purpose of allowing voluntary action to overcome the effects of conditions which might result in limited volunteer services of qualified handicapped individuals. Providing the information is voluntary, and failure to do so will not result in adverse treatment.
- Yes
- No
If not, could you perform these functions if a reasonable accommodation were made?*
- Yes
- No
References*
Name Profession Telephone

Please list the names, professions and telephone numbers of three references who are not relatives. (Preferably previous supervisors or instructors.)
In Case of Emergency Notify:*
Name Address Relationship Telephone
Referral Source:
- Newspaper / Radio Advertisement
- SCRMC Employee
- Other
Other:*

I certify that the answers given by me to the foregoing questions and statements are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications together with any information they may have regarding me, whether or not it is in their records. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. I understand that any falsification, misleading, incorrect, or omitted information will render this application void, and if accepted, would be cause for termination. I agree to submit myself upon request by the hospital for a LIMITED physical examination by Employee Health and to future physical or other examinations the hospital may require as a condition of continued volunteer service. (For Hospice volunteers, only) I further authorize the medical center to conduct a background check, including previous criminal convictions and previous employment/volunteer service. I understand that failure to list previous criminal convictions or employment/volunteer service above will void this application, and if accepted, would be cause for termination. If accepted, I agree as a condition of continued service to acquaint myself with, and to abide by all rules, regulations, and policies as established or amended by the hospital. However, I understand that my service can be terminated with or without notice at any time at the option of the hospital or myself. I authorize the hospital to release to future prospective employers any information regarding my volunteer service with the hospital. I hereby release the hospital from all liability for any damage for issuing this information. If I am accepted, I further understand and agree that when my service is terminated by retirement or otherwise, I must return all of Employer's property in my custody, including office keys, manuals, uniforms and identification card.*
Signature of Applicant
Today's Date*
MM slash DD slash YYYY
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Phone
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Adult Volunteer Application

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Adult Volunteer Application

Application for Adult Volunteer Services

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Dates	Company / Address / Telephone	Position / Job Duties	Supervisor's Name

Licesne / Certification	Number	Expiration Date

Services

Clinics & Medical Services

Adult Volunteer Application

Related Page Links

Adult Volunteer Application

Application for Adult Volunteer Services

Step 1 of 6

High School

College

Graduate School