College Student Application

A minimum commitment of sixty hours is required. Typically this is accomplished over the course of one or two semesters. Please consider your ability to make such a commitment before applying. Verification of volunteer hours will not be provided until the 60 hour threshold is met.

CONTACT INFORMATION

First name:

Last name:

Middle name:

Preferred Name:

Mailing Address:

City:

State:

* Zip: *

Home phone:

OK to call me here

Cell phone:

* OK to call me here

Email address:

Date of birth:

STUDENT STATUS

Current Student Status:

School Name:

DAYS/TIMES AVAILABLE

SPECIFIC AREAS OF INTEREST

You may read about current openings by visiting www.anmedhealth.org/volunteer and clicking on Volunteer Opportunities.

PREVIOUS VOLUNTEER EXPERIENCE

HOW DID YOU HEAR ABOUT OUR PROGRAM?

If you heard about our program from an AnMed Health volunteer or employee, please list that person's name.

EMERGENCY CONTACT

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

PERSONAL REFERENCES

Do NOT list relatives. Reference must be an adult 21 years of age or older and should be someone who has known you for at least 2 years.

1

2

First name:

Last name:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

* OK to call here

Cell phone:

* OK to call here

Connection:

CRIMINAL BACKGROUND STATEMENT

Have you ever been convicted, pled guilty, pled no contest, or forfeited bond to a violation of any federal, state, county or municipal law, regulation or ordinance other than minor traffic offenses (including bad check/fraudulent check & convictions as a result of court martial)?

Criminal Background:

If YES, list the date and place of the offense, the charge, and disposition.

Applicant Agreement

The information provided on this application is true in all respects, without any willful omissions. I understand that if this application is false in any way I may be dismissed without notice. By signing this application I give permission for the AnMed Health Volunteer Services department to contact the above named individuals in order to obtain personal reference information. As a participant in the volunteer program at AnMed Health, I:

- Agree to satisfy all orientation requirements

- Agree to comply with all policies and procedures of AnMed Health and the Volunteer Services Department

- Understand that I may be dismissed from my duties for any unauthorized viewing, discussion or disclosure of patient information

- Understand that volunteers are subject to "for cause" drug screenings

- Understand that I am not entitled to any form of compensation or benefits

I Agree