Avista Hospital Volunteer Application Form

Please complete this application form if you are interested in becoming a Avista Hospital volunteer. Once you complete the form, click the submit button at the bottom.

Your Contact Information:

First name:

Last name:

Street 1:

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:

Emergency Contact Informaion

Who shall we contact in case of Emergency?:

Kind:

Individual Group

First name:

Last name:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Personal Profile Infomation:

Date of birth:

Age:

Gender:

Education:

Assignment Preference

Please select below your preferences for assignment(s). You can click your mouse on any assignment below to view its description, times, etc.

* Assignment Preference:

Chaplain Volunteer [Chaplain's Department]

Gift Shop Assistant [Gift Shop]

Information Desk Clerk [Information Desk]

Medical/Surgical Department Assistant [Medical/Surgical]

New Life Desk Clerk [New Life]

Patient & Family Advisory Council [Volunteer Services]

Your Days/Times Available:

Please indicate the days/times you are usually available to volunteer:

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

Your Current Situation:

What are you doing now?:

High School Student
College Student
Working Full Time
Working Part Time
Retired
Other (please explain)

Current Situation:

Previous Volunteer Experience?

Do you have any previous volunteer experience? If so, please explain:

How Did You Hear About Us?:

How did you hear about our volunteer program at Avista?

Why Do You Want To Volunteer At Avista?

Significant Health Problems?

Do you have an significant health problems (either physical or emotional) that should be considered in your placement? If yes, please explain:

Any Felony Convictions?

Have you ever been convicted of any law violation other than a traffic violation? If yes, please explain:

Non-Family References

Please provide 2 non-family references who will say you would be a good volunteer:

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

Email address:

Comments:

I Agree

I understand and agree that submitting this application form does not automatically register me as a Avista 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.

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

I Agree