Please complete this application form if you are interested in becoming a Cheshire Medical Center volunteer. Once you complete the form, click the Continue button at the bottom to submit your application.


Identifying Information


Criminal History

(A conviction record may not prohibit you from becoming a volunteer. Factors such as your age when the offense(s) occurred, the recentness of the offense, the seriousness and nature of the violation, the nature of the position applied for and any rehabilitation undergone may be taken into account.


Have you ever been convicted of a felony or misdemeanor? If yes, please enter the following information: Name at time of conviction, type of conviction, date of conviction, location (City, State, County)



Professional or Personal References

References are people you have known for at least 1 year, not related to you, who can attest to your character and work ethic and may include people you have worked with/for.  For students, this includes teachers, coaches, scout leaders, youth leaders, babysitting, etc.



Previous Volunteer Experience

Enter any previous volunteer experience you might have in the field below. Please include the following information: Name of Agency, Duties/Responsibilities, Dates of Volunteer Experience.



Emergency Contact Information


Volunteer Availability

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



Skills or Qualifications


Statement of Policy

The Cheshire Medical Center/Dartmouth Hitchcock (CMC/DH) is an Equal Opportunity Employer.  Volunteer decisions are made without regard to race, color, religion, gender, sexual orientation, transgender status, national origin, citizenship, age, disability, marital and/or veteran status or any other legally protected status.

Certification by Applicant

I certify that the statements made on this application, and any addendum, are true, complete and correct.  I understand that any false statement or omission of any statement on this application and any addendum may be sufficient cause for rejection of my application or for dismissal, or other discipline as appropriate when any false statement or omission is discovered or confirmed subsequent to my volunteering.

Statement by Applicant

I expressly authorize, without reservation, CMD/DH, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or volunteer interview.   I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information about me.

General Conditions of Becoming a Volunteer

I understand that if CMC/DH decides to make me an offer to volunteer that any such offer is contingent upon pre-assessment criteria which may include medical and immunology screening and criminal records review.

I understand that CMC/DH does not unlawfully discriminate in its volunteers and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for volunteering on a basis prohibited by applicable local, state or federal law.

I agree to abide by and comply with all the rules/policies of CMC/DH.  If volunteering, I understand that the organization may unilaterally change or revise its policies and procedures.

I understand that I must successfully pass a Criminal Records Check and Department of Health and Human Services Records Release as a condition of volunteering.