Volunteer Application Form
Please complete this application form if you are interested in becoming a Hancock Regional Hospital volunteer. Once you complete the form, click the submit button at the bottom.
Name and address
First name:
*
Last name:
*
Middle name:
Street 1:
*
Street 2:
City:
*
State:
Choose
FLA
IL
IN
MI
PA
*
Zip:
*
Home phone:
Cell phone:
Email address:
*
1. Have you ever been convicted or pleaded guilty to a crime or misdemeanor? If yes, please explain below. (Such acts are not an absolute bar to volunteering, but will only be considered, in relation to specific assignments.)
Availability
Please indicate the days and times you are usually available to volunteer.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
My availability is:
Choose
Ongoing
Ongoing, except between these dates
Only between these dates
*
From:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
to:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
I would like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
*
Do you have any unresolved criminal or misdemeanor actions now pending against you? If yes, please explain.
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:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Gender:
Choose
Female
Male
SF
SM
Education:
Choose
Associate degree
College degree
Doctoral degree
High school
Masters degree
No
Some college
Trade/Vocational school
Yes
Any previous volunteer experience? If yes, what?
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
Schedule reminders
Here is the Monthy Schedule.If you are unable to volunteer on one of your scheduled shifts please let me know A.S.A.P.
Thanks,
Volunteer Services
Checklist reminders
How did you hear about volunteering at Hancock Regional Hospital?
Emergency Contact
In the case of an emergency, contact:
First name:
Last name:
Home phone:
Cell phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Sister
Son
Spouse
Supervisor
Wife
*
Refrence Section
List three references,who are not relatives, prefer employer, former employer, minister, etc.
1
2
First name:
First name:
Last name:
Last name:
Street 1:
Street 1:
Home phone:
Home phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Sister
Son
Spouse
Supervisor
Wife
*
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Sister
Son
Spouse
Supervisor
Wife
*
3
First name:
Last name:
Street 1:
Home phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Sister
Son
Spouse
Supervisor
Wife
*
Do you have any special skills or talents that could be utilized while volunteering at Hancock Regional Hospital?
ACKNOWLEDGMENT
I hereby certify that all information contained in this application is true and correct to the best of my knowledge.
I authorize the investigation of all statements contained in this application as may be necessary in arriving at a volunteer assignment decision, including reference checks and a criminal history background check.
I understand that, in the event of being accepted as volunteer, false and misleading information given through my application or interview(s) may result in discharge.
I Agree
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