Volunteer Application Form

Please complete this application form if you are interested in becoming an 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 completed.

Contact Information

Please complete the following information.

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

Demographics

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:

Have you volunteered here before and in what capacity?

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:

* OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Personal References

Please fully complete information for references. Please exclude relatives and others under 18 yrs. old.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

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

Employer

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

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Skills & Experience

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

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

Do you have any limitations related to health? Yes or No.If yes, please explain how this may effect your volunteering.

Email

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?

Electronic newsletters

Recruitment appeals

Expectations

Do you agree that you are willing to commit to a minimum of fifty(50) hours of volunteer services within a twelve (12) month period? Yes or No . Please include any additional comments.

I Agree

I understand and agree that submitting this application form does not automatically register me as a 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, creed, race, national origin, age or sexual orientation.

I also acknowledge that the organization is not obligated to provide a 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