Please complete this application form if you are interested in becoming a Dr. P. Phillips Hospital volunteer. Once you complete the form, click the submit button at the bottom.

Name and address

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

Email address:

Demographic Information

You are required to provide the following information. Some information may be used to complete a mandatory background check.

Date of birth:

Age:

Gender:

Social security #:

Education Background

If you are currently attending school please indicate the name of the school and your degree program.

Education:

School:

References

Please list the full name, mailing address and email address for three references. Include any combination of personal and professional reference sources; RELATIVES MAY NOT BE LISTED AS REFERENCE SOURCES. Your application WILL NOT be processed without complete information.

1

2

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

Cell phone:

Email address:

Relationship:

3

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

Cell phone:

Email address:

Relationship:

Past Work Experience

Please list the most recent name and address of your past employer. Also, list the name of your most recent supervisor/leader.

1

2

Employer name:

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Work phone:

Email address:

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Checklist reminders

Skills & Experience

Please list any special skills or talents that you would like to share with us.

Availability

Please indicate the days and times that you would like to share with us.

My availability is:

Emergency Contact Information

In the event of emergency, who do you prefer we contact.

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Criminal Background History (Yes/No)

Have you ever been convicted in a court of law, pleaded nolo contendre, been placed on probation, or had withheld to an offense other than a minor traffic violation? Note: Application will be considered incomplete if not filled in. Type in "N/A" if there are no convictions and if yes, please explain.

Background Check (Yes/No):

Answer Yes or No. Do not leave blank. If "yes" please explain.