Thank you for your interest in volunteer services at Norton Women’s & Children’s Hospital. Please complete this application, as it will be reviewed for consideration.

Once you complete the form, click the submit button at the bottom. By submitting this form you are giving Norton Healthcare permission to perform a criminal background check.

Contact Information and References

I authorize the release of information to be sent to my references listed on my application. Please enter two references listed below numbered 1 and 2.

First name:

Last name:

Title:

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

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

Demographic Information

Please 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:

Referral:

Social Security Number:

Skills and Experience

Please list your skills and any physical limitations.

Availability

Please indicate the day(s) and time(s) you are available to volunteer.

Assignment Preference

The following volunteer assignments may currently be available. Use this list to rank your top three assignment choices.

* Assignment Preference:

1st choice:

2nd choice:

3rd choice:

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Relationship:

Employer

Please list your current or most recent employer, if applicable.

Employer name:

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

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.

Email address:

What kinds of email would you like to receive?

Work Related

Personal

I Agree

I understand and agree that submitting this application form does not automatically register me as a Norton Healthcare 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. Submission of this application affirms that I give permission for a criminal background check if I am 18 or older.

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

I Agree