Volunteer Application Form

Thank you for your interest in volunteering with Mary Washington Healthcare (MWHC). MWHC holds the safety of everyone in our facilities as a top priority. Novel coronavirus, or COVID-19, is a big concern in our community. Please note: Covid-19 vaccinations are mandatory for all volunteers. Proof of vaccinaton is required.

Thank you!

Contact Information

For the required fields, please type "none" if it does not apply to you.

First name:

Last name:

Title:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

* OK to call me here

Email address:

Preferred Location

Please click on the location you would prefer to volunteer.

* Preference:

Mary Washington Hospital

Stafford Hospital

Demographics

Please provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

* (year optional)

Are you currently retired?:

Are you a Veteran?:

Employment

If you are currently working or have worked in the past five years, please provide the following information. If you have not worked within the past five years, please type "none" in all spaces.

1

2

Employer Name:

City:

State:

Work phone:

If you have any volunteer experience, please list location and timeframes here.

Help us get to know you.

Please select your highest level of education.

Highest level of education completed:

If you are currently enrolled, please give the name of the school and your course of study.

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Please list any skills or strengths that make you an ideal volunteer candidate.

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Why do you want to volunteer at MWHC?

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How would others describe your dependability?

Availability

Please indicate the days and times you are usually available to volunteer.

Emergency Contact

In the event of an emergency, who should we notify?

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2

First name:

Last name:

Street 1:

City:

State:

Home phone:

Cell phone:

Other phone:

Relationship:

Background

Pursuant to the Code of Virginia all applicants must affirmatively identify any criminal conviction or pending

criminal charge whether within or outside the Commonwealth of Virginia. Applicants are not required to disclose arrests, charges or convictions that have been expunged. Conviction of a crime is not an absolute bar to volunteering. We will take into account the nature and gravity of the offense or offenses, the frequency of the offenses and the interval between them, the time that has passed since the conviction and/or completion of sentence, and the nature of the volunteer work to which the applicant has applied. With that information in mind, please answer the following question:

Have you ever been convicted of a crime other than a minor traffic violation or have any criminal charges pending against you?

If yes to either of the above, please explain.

I Agree

I understand and agree that submitting this application form does not automatically register me as a Mary Washington Healthcare Volunteer. If selected for Volunteer service with Mary Washington Healthcare, I understand and agree to comply with the requirements and regulations of the Hospital. I agree to accept responsibility to honor the commitment of time for which I am scheduled and to provide adequate notice when I am unable to report for duty. I understand that this is a voluntary commitment that may be terminated at any time.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree