CRH Volunteer Application Form

Please complete this application form if you are interested in becoming a Chesapeake Regional Healthcare volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information

Please be aware when filling out this portion of your application:

Adult means: 18+ not attached to a particular academic program;

College means: 18+ attached to a specific adademic program requiring verified hours;

Student means: less than 18 years of age and should only be applying to our program between March 1st through May 15th of each year. Student information packets will be available March 1st of each year.

First name:

Last name:

Middle name:

Title:

Nickname:

Type:

Street 1:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

OK to call me here

EMail

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

Email address:

Demographics

Please 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:

Age:

Gender:

Level of Education:

Major degree:

Name of School:

Still in school? Graduation Date:

How did you hear about our program?:

Skills & Experience

In which of these areas do you feel you have moderate to excellent skill? Check all that apply.

Interest

What are you interested in doing, or willing to do (with training) as a volunteer. Check all that apply.

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

I would like to serve up to:

hours:

Assignment Preference

The following volunteer areas may currently be available. Use this list to rank your top three assignment choices.

Assignment Preference:

1st choice:

2nd choice:

3rd choice:

If you selected Compassionate Companions as one of your preferences please explain your interest &/or experience in this area.

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Home phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Employer

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

Employer name:

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Home phone:

Personal References

Please supply two personal references.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

OK to call here

Home phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Contacted:

Verified:

Criminal Background

Have you ever been convicted of, or pled guilty to a criminal offense (misdemeanor or felony? We do criminal checks. Conviction of a felony will not be an automatic or absolute bar for volunteering at Chesapeake Regional Medical Center. Any conviction will be considered in relation to specific job requirements. Flasification of this or any other informaiton on the application is grounds for immediate termination. A conviction does not necessarily disqualify you from volunteering.

* Been convicted of a felony?:

Yes

* Had court ordered communnity service?:

Yes

If you answer yes to either of the above please explain.

I Agree

I understand and agree that submitting this application form does not automatically register me as a Chesapeake Regional Healthcare 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.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree