Adult Volunteer Application

Please complete this application form if you are interested in becoming a Wellspan Health volunteer.

Once you complete the form, click the submit button at the bottom.

PLEASE NOTE: Submitting an application does not guarantee acceptance into the Wellspan Health Volunteer Program. Your application will be reviewed and if initial qualifications are met, you will be contacted (via email or phone) to schedule an Orientation session. Once you have attended Orientation, an interview will be conducted to determine placement as well as a Health Screening and additional training (if needed).

Applicant Information:

Please provide your legal name (i.e. no nicknames).

Emergency Contact:

In the event of an emergency whom should we notify?

First name:

Last name:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

* OK to call here

Relationship:

Education, Special Training, Skills:

Please list your education and any special training or skills:

Education:

Occupation:

Current Occupation:

Work status:

Work phone:

OK to call here

Please list name of employer, occupation and employer phone number:

Volunteer Interest:

Please tell us why you want to volunteer with Wellspan Health?

Volunteer Experience:

Have you volunteered in the past? If yes, please list the name of the agency, date and volunteer role.

Availability:

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

Please list the number of days or hours per week you would like to serve as a volunteer.

Requirement:

Wellspan requires a minimum of 100 volunteer hours, completed within twelve month period from your start date.

* Are you willing to make this commitment:

Yes

If no, please explain:

Assignment:

Preferred Location:

Miscellaneous:

Note: A conviction record does not necessarily prevent you from volunteering for Wellspan.

* Community Service Requirement:

Yes

Have you ever been convicted of a crime:

Yes

If yes, please state offense, date and location.

References:

Please provide us with names and email addresses of two (2) personal references who can comment on your ability to serve as a volunteer. All references will be contacted.

References cannot be relatives and must have known you for at least one(1) year.

1

2

First name:

Last name:

Email address:

Relationship:

I Agree

I hereby certify that all statements and answers set forth on the application are true and complete to the best of my knowledge. I understand that if any statements and/or answers are found false or information has been omitted, such false statements or omissions may be cause for rejection or termination of my volunteer application or service. I understand that in processing my application with WellSpan Health Volunteer Engagement, an investigative report will be conducted to obtain and verify information relating to my past activities and background. Information may include, but is not limited to: criminal records, child abuse clearances and any data provided on this application or during the interview process. I permit the Volunteer Engagement department to use my name, photograph or video as a volunteer for publicity purposes when necessary.

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

I Agree