Application Form – Adult Volunteer

Please complete this application form if you are interested in becoming a Capital Health Adult Volunteer. Once you complete the form, click the submit button at the bottom.

Personal 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

Email address:

Physician's Name:

Physician's Phone:

What kinds of email would you like to receive?

Electronic Newsletters
Please find the Volunteer Services Newsletter

Important Time Sensitive News
Please see this important news from Capital Health's Volunteer Services Department

Auxiliary News
News about the Auxiliary events and happenings

Regular Volunteer News
Main news and updates

Demographic Information

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:

Gender:

Education:

Ethnicity:

Race:

School:

How did you hear about our program?:

Applicant Questions

What is the reason you'd like to volunteer and what do you envision yourself doing if selected for the program?

Volunteer History

Please share your recent employment history or volunteer experience

Availability

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

Special Skills & Qualifications

Summarize special skills and qualifications acquired from employment, volunteer work, or other experience, such as hobbies, sports, etc.

Criminal History

Have you ever been convicted of, or pled guilty to a criminal offense (misdemeanor or felony)? (We do criminal checks. Falsification of this or any other information on the application is grounds for immediate termination. A conviction does not necessarily disqualify you from volunteering.)

Criminal Question:

If 'Yes' please explain

References

Please list 2 non-family references

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Work phone:

* OK to call here

Work phone:

* OK to call here

Cell phone:

* OK to call here

Cell phone:

* OK to call here

Email address:

Emergency Contact

Please list one emergency contact

First name:

Last name:

Street 1:

City:

State:

Zip:

Cell phone:

* OK to call here

I Agree to the following terms:

All applicants are considered for available positions for which they are qualified without regard to race, color, religion, sex, national origin, age, disability, or veteran status.

My confirmation below affirms that all the facts set forth in my application for are accurate and complete.

I Agree