Summer Teen Program Volunteer Application

Please complete this application form if you are interested in becoming an Aultman Alliance Community Hospital volunteer. Once you complete the form, click the submit button at the bottom.

The form will not submit until all boxes with an *asterisk have been completd.

Name and address

Please complete all information in full.

First name:

Last name:

Title:

Nickname:

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:

OK to call me here

Email address:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Gender:

Education:

School:

Which high school are you attending and who is your guidance counselor?

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

Emergency Contact

Who should we notify in the event of an emergency.

First name:

Last name:

Street 1:

City:

State:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

References

Please complete two references. Your references need to be over the age of 18 and not a relative.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Email address:

Relationship:

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

Background Check Information

Have you ever been convicted of a crime other than a minor traffic violation? Yes of no. If yes, please explain further.

Skills & Experience

In which areas do you feel you have moderate to excellent skills? Check all that apply.

Why are you interested in volunteering?

I agree

I understand and agree that submitting this application form does not automatically register me as an Alliance Community Hospital Volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

I understand that opportunities for volunteers are provided without regard to religion, race, creed, national origin, age or sexual orientation.

I also acknowledge that the organization is not obligated to provide placement, nor am I obligated to accept the position. I understand that I am required to abide by all rules and regulations of Alliance Community Hospital and the Volunteer Services Department.

By submitting this form, I attest that the information I have provided on the form is true and accurate. Any misrepresentation would void the applicant from the volunteer program.

I Agree