Volunteer application form for Via Christi Rehabilitation Hospital

Please complete this application form if you are interested in becoming a volunteer at VIA CHRISTI REHABILITATION HOSPITAL. Once you complete the form, click the submit button at the bottom.

Contact Information

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

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:

Social security #:

Skills & Experience

Please describe the areas in which you feel you have moderate to excellent skill.

Availability

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

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Relationship:

Employer

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

Employer name:

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

References

Please provide three adult references, not relatives, you have known for at least 2 years.

1

2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Cell phone:

3

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Cell phone:

Relationships at Via Christi

Below, please provide the name(s) and relationship of relatives or friends currently employed by or volunteering at Via Christi

1

2

First name:

Last name:

Title:

Relationship:

3

First name:

Last name:

Title:

Relationship:

I Agree

I understand and agree that submitting this application form does not automatically register me as a VIA CHRISTI HOSPITALS WICHITA 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