Patient/Family Program Application

Applicant Contact Information

First name:

Last name:

Middle name:

Nickname:

Street 1:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Social security number:

Type of Visa:

Demographic Information

Date of birth:

Gender:

Education:

Race:

Ethnicity:

Site Location Preference

Moffitt location you are interested in volunteering:

* Choose one or more:

ALL

Magnolia (USF) Campus

Moffitt International Campus

Other Programs

Availability

Emergency Contact

First name:

Last name:

Home phone:

Cell phone:

Relationship:

Background Check

Please provide answers for questions 1 and 2 in the box provided: 1. Have you ever been convicted of any crime, pled guilty or no contest to any crime, or had a criminal adjudication withheld? Please answer yes or no. If yes, please explain: 2. Do you have any unresolved arrests, warrants or pending criminal charges against you? Please answer yes or no. If yes, please explain:

Background Check

Are you legally eligible to volunteer in the United States? Please answer yes or no.

Background Check

Regarding civil lawsuits or administrative complaints alleging child abuse, spouse abuse, elder abuse, patient abuse, harassment and/or dishonest, violent or discriminatory conduct (such as fraud, embezzlement, theft, assault, battery, etc.) have you ever been found liable (i.e., judgment was rendered against you) in any such matter, or is any such matter currently pending against you? Please answer yes or no.

Why would you like to volunteer with Moffitt?

How did you hear about Moffitt's volunteer program

* Choose one or more:

If referred, please provide name:

Referred by:

References

Please provide two non-relative references. Examples, employer, coach, teacher, etc.

1

2

First name:

Last name:

Home phone:

Email address: