ANNIE PENN HOSPITAL CAMPUS VOLUNTEER APPLICATION

Please complete this application form if you are interested in becoming a Annie Penn Hospital Volunteer Services volunteer. Once you complete the form, click the CONTINUE button at the bottom.

CONTACT INFORMATION

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work 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:

AVAILABILITY

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

ASSIGNMENT PREFERENCE

The following volunteer assignments may currently be available. You may click the assignment names to learn more that assignment.

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:

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 Moses Cone Memorial 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