Winship Volunteer Services Application

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

CONTACT INFORMATION:

First name:

Last name:

Middle name:

Title:

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

Fax phone:

Email address:

Date of birth:

Age:

What kinds of email would you like to receive?

Volunteer Newsletter

Recruitment appeals

Schedule reminders

Checklist reminders

Employer name:

Work phone:

ADDITIONAL VOLUNTEER INFORMATION (Optional):

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.

Gender:

Ethnicity:

Skills:

EDUCATION:

Please list the last two educational institutions that you attended, beginning with the most current.

Education:

College Major:

College Name:

PERSONAL REFERENCE:

The information provided in this application thus far is complete and correct to the best of my knowledge. I understand I am applying for a volunteer position and that references which I will provide may be contacted.

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:

Relationship:

EMERGENCY CONTACT INFORMATION:

In case of an emergency, please list two individuals who can contact.

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:

Email address:

Relationship:

VOLUNTEER AVAILABILITY:

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

AREAS OF INTEREST:

* Assignment Preference:

1st choice:

2nd choice:

3rd choice:

4th choice:

LOCATION PREFERENCE:

Please indicate the location(s) that you would like to be considered for:

* Location Preference:

1st choice:

2nd choice:

3rd choice:

4th choice:

5th choice:

6th choice:

PERSONAL STATEMENT:

Please briefly discuss why you would like to volunteer at the Winship Cancer Institute and your specific areas of interest. Additionally, please let us know your expectations as a volunteer.

MEDICAL INFORMATION:

Volunteers who are cancer survivors are required to have been out of treatment for at least 6 months prior to volunteering. Additionally, volunteers who have had a family member recently pass away from cancer will need to delay volunteering for at least 12 months.

Physician's Name:

Physician's Phone Number:

Cancer Survivor?:

If yes, would you share your experience:

VOLUNTEER COMMITTMENT PLEDGE & STATEMENT:

I pledge my committment as a volunteer at Emory Winship Cancer Institute:

*I shall be conscientious in the fullfillment of my duties and accept supervision graciously.

*I shall wear the appropriate volunteer uniform while in service.

*I shall conduct myself with dignity, courtesy and consideration.

*I shall endeavor to make my work of the highest quality.

*I shall not provide any medical advice, interpretation, or suggestion to any patients, family members or caregivers.

*I shall consider all information that I may hear directly or indirectly concerning those we serve as confidential.

*I shall share any questions, issues or concerns with the Volunteer Services Office and Supervisor.

*I shall uphold the traditions and reputation of the Winship Cancer Institute and as an ambassador I will interpret them to the community at large.

*I agree to fulfill a 6 month committment, completing at least 8 hours a month (the equivalent of two 4 hour shifts per month).

*I recognize that inappropriate behavior will result in immediate dismissal from the program.

*I hereby certify that if I qualify, I will need to complete the entire application process. Additionally, I understand that misrepresentation, falsification or omission of information may disqualify me from volunteer service.

I Agree