Volunteer Application Form

ALL APPLICANTS MUST BE 18 OR OLDER TO APPLY. Please complete this application form if you are interested in becoming a UAMS Medical Center Volunteer. Required information is indicated with an asterisk. Once you complete the form, click the Continue button at the bottom.

NOTE: The deadline to submit your application to volunteer for the summer is now over. Accepting only ongoing volunteers from this point forward.

Name and Address

This information will be used to contact you. Please provide a working phone number and e-mail address. We are required to obtain your social security number for security purposes. All information will remain protected and will not be shared.

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Best Contact Number phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Fax phone:

OK to call me here

Other phone:

OK to call me here

Email address:

Social security number:

Demographic Information

The following information will be used to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Age range:

Gender:

Education:

Ethnicity:

Marital status:

T-Shirt size:

Work History

Please provide information regarding your two most recent employers, if possible.

Employer name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

Other phone:

Email address:

Educational Background

Please provide information regarding your educational history.

Major degree:

Previous ICU Experience?:

Previous Experience at UAMS?:

High School:

College/University:

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

Hours Available to serve:

Each:

Volunteer Interest

Please indicate the areas in which you would be interested in volunteering. To read specific service descriptions, click the links.

Emergency Contact Information

Please provide information for someone the Volunteer Services Department may contact in case of emergency.

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Other phone:

Relationship:

References

Please provide two non-family references who may speak to your skills, abilities and capabilities for volunteering.

1

2

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

Other phone:

Email address:

Relationship:

Contacted:

Verified:

Password Creation

Please select a password of your choice. This will be the password you use when using the online volunteer database.

Please enter a password that:

Is between 6 and 30 characters long

Password:

Confirm password:

Volunteer Agreement

By submitting this application I agree to uphold the rules and regulations of the UAMS Medical Center Department of Volunteer Services and agree to complete all of the necessary components to become a volunteer.

I Agree