Please complete this application form if you are interested in becoming a Carle Foundation Hospital Auxiliary Volunteer at the Urbana Campus.

Our Critical Needs areas for the Auxiliary are: Ambassadors [information desk, escorting/wheelchair transport, wayfinding and greeting], Gift Shops, Guest House, Mills Cancer Center, Surgical Waiting Room, and helping with fundraisers. However, we have opportunities to fit many different interests and talents.

Once you complete the form, click the continue button at the bottom.

Name and address

First name:

Last name:

Middle name:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

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:

Education:

Veteran:

School:

Skills

What skills do you have that could help impact the patient experience?

Interest Areas

What Critical Needs Area are you interested in giving service? What other areas are you interested in giving service?

Availablity

Please fill in your availability below.

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

I would like to serve up to:

hours:

References

Please include contact information for at least 2 (up to 3) individuals that would be a reference for you.

1

2

Employer name:

First name:

Last name:

City:

Work phone:

Cell phone:

Email address:

Relationship:

3

Employer name:

First name:

Last name:

City:

Work phone:

Cell phone:

Email address:

Relationship:

Emergency Contact

Please enter your preferred emergency contact below.

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Volunteer Experience Goal*

What are you hoping to gain from this volunteer experience?* (Required)

Read the following carefully before continuing:

In submitting this application for volunteering with Carle, I understand that an investigation may be made whereby information is obtained regarding my character, previous employment, general reputation, education and/or criminal history.

In consideration of review by The Carle Foundation, Subsidiaries and Affiliates, of my Volunteer Application and consideration of me for this program, I agree as follows:

1. I understand that pursuant to the Americans with Disabilities Act and other laws, I may request a reasonable accommodation in completing this Application and interview process. Contact Volunteer Services staff to request an accommodation.

2. I understand and agree that all information furnished in this application may be investigated by The Carle Foundation, Subsidiaries and Affiliates or its authorized representatives. I waive any right I may have to notice from any individuals or organizations named or referred to in this application prior to the release of any information to The Carle Foundation, Subsidiaries and Affiliates. I hereby authorize all individuals in organizations named or referred to in this application and any law enforcement organization to give The Carle Foundation, Subsidiaries and Affiliates all information that relates to or is requested during an investigation, and I hereby release those individuals, organizations and The Carle Foundation, Subsidiaries and Affiliates from any and all liability for any claim or damage resulting therefrom.

3. If offered a volunteer role, I understand that such offer may be contingent on passing a medical examination, the purpose of which is to determine my ability to perform the essential functions of my volunteer role. I authorize The Carle Foundation and its Subsidiaries and Affiliates to conduct an investigation as to my medical history and I authorize any medical institution to release any medical information including, but not limited to, medical records which may be necessary to determine my ability to perform the essential functions of my volunteer role.

4. I understand that The Carle Foundation, Subsidiaries and Affiliates are not obligated to provide acceptance into this program and that I am not obligated to accept a volunteer position. Nothing in this application, or in any prior or subsequent oral or written statement or communication, is intended to create any contract of employment or to create any rights in the nature of a contract. This application does not bind either party for a specific period of time regarding a volunteer position. If accepted, I understand that nothing shall restrict my right as a volunteer or the right of The Carle Foundation, Subsidiaries of Affiliates to terminate my position as a volunteer at any time for any reason.

5. I understand that, if accepted, I am required to abide by all the rules and regulations of The Carle Foundation, Subsidiaries and Affiliates and to comply with all the policies and procedures in the employee handbook, volunteer manual, any policy or procedure manual, or other communications to volunteers. I further understand that policies and procedures of The Carle Foundation and all subsidiaries and affiliates and all employment terms and conditions are subject to modifications without notice.

6. The information contained in this application is accurate and complete to the best of my knowledge and belief.

Checking this box below shall have the same force and effect as my written signature.

I Agree