ADULT Volunteer Application

(Please Print)

Date _________________

Social Security # __________________________

Name _______________________________________________________________
Last

First

Middle

Address _____________________________________________________________
Street

City

Telephone (Home) (_____) ________________

Zip

(Work) (___) __________________

E-Mail __________________________ Birth (Month/Day/Year) _________________

How long have you lived at your present address? __________________________
How long have you lived in this County? ___________________________________
If less than five (5) years, please list your former county and state of residence:
County/State _________________________ Date(s) of Residency ______________
Emergency Contact __________________________ Telephone (___) ____________
Relationship __________________________________________________________
Are you presently employed? Yes / No (circle one) Please list current or last place of employment

Company ____________________________ Occupation ______________________

Are you a student? ____ If so, where? ___________________ Major____________
Special skills or interests ________________________________________________

Are you fluent in any languages in addition to English? (Yes/No)

Which Languages ____________________________________________Read/Write)
How did you hear about volunteer opportunities at All Childrens Hospital?
Friend ___ Media ____ Relative____ Employee____ Internet____ Other____
Please Specify ________________________________________________________
Why would you like to volunteer at All Childrens Hospital? ___________________
______________________________________________________________________
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Have you done or are you currently doing any other volunteer work (Yes / No)
Please Specify ________________________________________________________

Community Affiliations (Civic/Social) ______________________________________

Do you have any physical limitations which may require a reasonable accommodation in
order for you to perform the duties of a volunteer? Please explain ____________________

Have you ever been convicted of a felony, misdemeanor, or other criminal

offenses and/or, are there any arrests or criminal proceedings currently pending
against you? (Yes / No)
If yes, explain (A conviction record may not necessarily be a disqualification to volunteer)

______________________________________________________________________
Availability: Weekdays

_____ Mornings _____ Afternoons _____Evenings

Weekends

_____ Mornings _____ Afternoons _____Evenings

Specific days and times requested ________________________________________

Are you available to assist with special projects? ___________________________

Statement of Understanding and Agreement

I certify that the information given by me in this application is true in all respects and that I have
not made any willful omissions. I agree to abide by all present and subsequent rules and
regulations of All Childrens Hospital, and I understand such rules and regulations may be
modified at any time the hospital determines that it is necessary.
In making this volunteer application, I hereby authorize All Childrens Hospital and all of their
agents to request and receive a criminal background check concerning convictions that may of
occurred at any time in my past. I understand that I will be notified by All Childrens Hospital with
information concerning any convictions that may be discovered.
I understand that disclosure of confidential information concerning the hospital or a patient may
cause immediate dismissal. As a volunteer, I agree to attend orientation and participate in
appropriate inservice programs as needed to fulfill my duties.

Signature _____________________________________ Date _________________

Interviewer ____________________________________ Date ________________

Department Director _____________________________ Date __________________