Adult Volunteer Application Form

Asterisk (*) indicates a required field.

Please read all of the instructions on this application.

The opportunity to become a volunteer could be for you if you meet the following:

•Have a desire to serve others

•Have a compassion and love for people

•Have reasonably good mobility, as most services require walking and/or pushing wheelchairs

•Must be willing to make a one-year commitment of a weekly three or four-hour shift. Available shifts are 7:30 a.m.-12 p.m.; 12-4 p.m.; and 4-7 p.m.

•At least 18 years of age

NOTE:

We strive to match your interests and our needs; however certain shifts may be limited. To help with your placement, please be sure to note your availability on this form.

Once you complete the form, click the "Continue" button at the bottom to submit your application.

Name and Address

First name:

Last name:

Middle:

Nickname:

Street:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Birth Date:

Education

If applicable, please indicate your school address in this section.

Highest Level of Education:

Are you currently enrolled in school?:

School:

What is your major and your anticipated graduation date?

Employment

Employment:

Full Time

Out of Workforce

Part Time

Retired

Employer Name:

Occupation:

Volunteer Experience

Please list any previous volunteer experience. Include location and length of time you volunteered.

Please let us know any information or skills you have which may be relevant to volunteering at OSF

Why do you want to volunteer?

Hospitals exist to improve or maintain patients' health, so anything you do to help the hospital is, directly or indirectly, making people healthier and improving their lives.

How did you hear about OSF HealthCare?

* How did you hear about OSF HealthCare?:

If you selected "Other" in the box above, please give further details here. Also, if you selected "Current OSF volunteer" tell us who so we can thank them!

Conviction Records

Have you ever pled guilty to or been convicted of a crime other than a minor traffic offense? This does not include minor traffic violations or convictions that have been sealed or expunged.

* Conviction Record:

Yes

If yes, please explain:

Volunteer Availablility

Volunteer shifts are 3 – 4 hours scheduled according to the department need. Volunteers are asked to make a minimum commitment of one shift per week for 1 year. Please check your availability: Mornings:7:30am-12pm; Afternoons:12pm-4pm; Evenings:4pm-7pm

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

If you need an accommodation while volunteering, please describe here

When finished with this application...

Select "Continue" at the bottom of this form **or** print it out and send your completed application to:

OSF HealthCare Volunteer Services

5666 E. State Street

Rockford, IL. 61108

Fax: (815) 227-2592

Phone: (815) 395-5064

CAREFULLY READ THIS SECTION:

By checking the "I Agree" box and selecting the "Continue" button below: I hereby affirm that the information on this application is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for a volunteer position and may result in discharge even if discovered a later date.

I understand that as part of the application process, that a criminal background check may be conducted. I understand that OSF HealthCare is not obligated to provide placement, nor are you obligated to accept a position if one is offered. Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, or sex.

I Agree