WellStar Cobb Hospital Volunteer Application Form

Please complete this application form if you are interested in becoming a WellStar

Cobb Hospital Volunteer Services Department volunteer. Once you complete the form, click the submit button at

the bottom.

COLLEGE STUDENTS

If you are a college student seeking summer volunteer opportunities please note that you must complete the application and onboarding process by May 31 to be eligible to volunteer as a summer college student.

Name and address

First name:

Last name:

Title:

Preferred Name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

Date of birth:

Gender:

Facility:

Skills and Experience

Please tell us why you would like to volunteer at WellStar Cobb Hospital. Also, please provide a brief description
of your relevant skills and experience that may assist us in determining what placement will best fit your skills.

Emergency Contact

In case of an emergency, who should we contact?

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Employment

Are you currently seeking employment? If so, please explain.

Employer

If you are currently employed please provide us with the following information.

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

How did you hear about us...

How did you hear about WellStar Cobb Volunteer Services? (Newspaper, Friend, Human Resources, School,
Website, Internet, Employee's Name,Volunteer's Name)

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

Cobb 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.

*We consider the safety and security of our patients, visitors, staff & volunteers to be of the utmost importance.

Applicants must sign a release for a Background History screening for criminal background histories by state and federal agencies. Persons who have been convicted of any felony offense or misdemeanor offenses involving drugs, child abuse,

assault, and/or any violent behavior are not eligible to volunteer in our program. There are no exceptions.

Reminder: The Volunteer Medical Release Form has to be printed and must be filled out and signed by a licensed physician or Nurse practitioner (The form is available on the Volunteer page where the application link is located). Also, if you were

born after 1957, an immunization record must be submitted.

I agree that my submission of this application attests that all of the information contained in this application and

the documents forwarded in addition to the application are true.

I Agree