Please complete this application if you are interested in becoming a Wesley Long Hospital Campus volunteer. Once you complete the form, click CONTINUE at the bottom of the application.

CONTACT INFORMATION

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

PROFESSIONAL REFERENCES

1

2

First name:

Last name:

Home phone:

Cell phone:

Email address:

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:

* (year optional)

Gender:

How did you hear about us?

AVAILABILITY

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

ASSIGNMENT PREFERENCE

The following volunteer assignments may currently be available.

Assignment Preference:

Central Waiting Area Receptionist [Wesley Long Hospital\Volunteer Services]

CHCC - Patient & Family Assistant (Main Lobby) [Wesley Long - Cancer Center\Volunteer Services]

Family and Patient Concierge [Wesley Long Hospital\Volunteer Services]

Gift Shop [Wesley Long Hospital\Volunteer Services]

EMERGENCY CONTACT

In the event of an emergency whom should we notify?

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

EMPLOYER

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

Employer name:

Work phone:

Email address:

SPECIFIC VOLUNTEER AREA OF INTEREST

Please share with us your motivation for volunteering in hospital-based setting.

I Agree

I understand and agree that submitting this application form does not automatically register me as a Wesley Long 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 certify that the information given by me in this application is true in all respects, and I agree that if accepted as a volunteer and it is found to be false in any way that I may be subject to dismissal, without notice, if and when discovered. I authorize the use of any information in this application to enable the hospital to verify my statements and I authorize past employers, doctors, all references, and any other persons to answer all questions asked by Cone Health concerning my ability, character, reputation and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I further agree, if accepted in the program, that I am to volunteer faithfully and diligently, to be careful and avoid accidents, report to my shift promptly and to notify Volunteer Services should I be absent for any reason.

I agree to abide by all present and subsequently issued policies and rules of Cone Health and Volunteer Services.

I Agree