Please complete this application form if you are over the age of 18, able to commit to 100 hours of total service, working one volunteer shift ( 3 hours ) every week and are interested in becoming a Gillette Children's Specialty Healthcare volunteer.

A valid email address is required to complete this application. Email addresses are kept confidential and are not shared.

You will be contacted about next steps once your application and two references are received.

16-17 year olds: Please see our Summer Student Volunteer Application, available January- March.

All items with an asterick(*) are required fields. Once you complete the form, click the submit button at the bottom.

Name & Address

First name:

Last name:

Middle name:

Address:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Gender:

Ethnicity:

Therapy Dog Organization:

College currently attending:

Job Title:

Employer:

Check if you are over the age of 18.:

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Other phone:

Relationship:

Skills & Interests

Please indicate any special skills you would like to share with us (musical instruments, languages you are fluent in, etc).

Availability

Volunteer shifts are typically 3-4 hours, once a week. Volunteers are asked to make a minimum committment of one shift per week for 6 months. Please indicate the days times you are available to volunteer.

Location Preference

Please select the locations that are of interest to you.

* Location Preference:

1st choice:

2nd choice:

3rd choice:

Other:

Background Information

Have you ever been convicted of, pled guilty to, or pled no contest to a crime other than a traffic offense or petty misdemeanor?

If you have been convicted of a crime and believe the crime you have committed is no longer on your criminal record, you must still disclose the information. Answering "yes" to the question posted above will not, by itself, constitute an absolute bar to being considered for volunteer assignemnt.

Yes:

No:

Volunteer/Work Experience

Please list any past or current volunteer or paid work experience.

Why are you interested in volunteering at Gillette

How did you hear about our volunteer program?

I Agree

I authorize a complete investigation by Gillette Children's Specialty Healthcare of the information about me on this application and of my prior work experience. I release my prior employers from any liability and hold them harmless for any information about my work experience or performance that they give to Gillette Children's. I understand that my volunteer status is conditional until 1) I have provided documentation of all required vaccinations and a negative Q-Gold TB test; and 2) I successfully pass a criminal background check. I also understand that if I am invited to volunteer at Gillette children's my volunteer commitment will be for an indefinite period of time which means that either I or Gillette Children's may end this relationship at any time.

Gillette Children's Specialty Healthcare is not obligated to provide placement, nor are you obligated to accept the volunteer position offered.

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

I Agree