Adult Volunteer Application
Please complete this application form if you are interested in becoming an adult volunteer with Atrium Health Cleveland and/or Atrium Health Kings Mountain. Once you complete the form, read and agree, then click the continue button at the bottom.
Applicant Information
First name:
Last name:
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Nickname:
Street 1:
Street 2:
City:
State:
Choose
NC
SC
Zip:
Home phone:
OK to call me here
Cell phone:
OK to call me here
Email address:
How did you become interested in volunteering?
Education
List the highest level of education completed.
Volunteer Experience
List your volunteer experience. Include the organization's name, length of volunteer time and volunteer role.
Employment History
List your most current employment, telephone number, position and dates of employment
Reference Information
Please do not use a relative for reference
1
2
First name:
First name:
Last name:
Last name:
Street 1:
Street 1:
Street 2:
Street 2:
City:
City:
State:
Choose
NC
SC
State:
Choose
NC
SC
Zip:
Zip:
Home phone:
OK to call here
Home phone:
OK to call here
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:
Email address:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Emergency Contact Information
First name:
Last name:
Home phone:
OK to call here
Work phone:
OK to call here
Cell phone:
OK to call here
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Background Disclosure
Atrium Health Cleveland and/or Atrium Health Kings Mountain obtain arrest and conviction records on all potential volunteers. An arrest or conviction will not automatically eliminate you from consideration for volunteering. However, failure to list all pending charges and/or convictions may lead to your disqualification or termination of volunteering with Atrium Health Cleveland and/or Atrium Health Kings Mountain. Examples may include, but should not be limited to: driving while impaired, worthless checks, assault, driving while license is suspended, disorderly conduct, credit card fraud, embezzlement, etc.
Have you ever been convicted of any criminal violation of law, or are you now subject to a pending investigation of
charges for violation of criminal law?
Please Answer Yes or No. If yes, please explain
Volunteer Applicant Agreement
As a volunteer for Atrium Health Cleveland and/or Atrium Health Kings Mountain I understand:
I will consider as confidential all information which I may hear or see, directly or indirectly, concerning a patient, family member, doctor, or other health care professional and I will not seek information from any of the above in regard to a patient.
I must certify that the answers to the application and any resulting from interviews are true and correct and that any misrepresentations or omissions of facts, misleading, or false information on my part will be grounds for dismissal as a volunteer. (Acceptance as a volunteer is contingent upon satisfactory references, verification of information submitted on the application and satisfactory completion of mandatory requirements.) My acceptance of this agreement authorizes Atrium Heath for the purpose of contacting my references and the employers, schools, or references thus contacted are hereby released from all liability in answering questions related to my application.
My services are donated to Atrium Health without contemplation of compensation or future employment and given with humanitarian or charitable reasons.
I authorize Atrium Health to administer emergency medical treatment to me while volunteering. I understand that Atrium Health is not responsible for volunteers after their assigned volunteer shifts have ended.
Filing an application does not assure volunteer placement since the number of applicants can exceed the number of available openings.
Volunteer applications are only held for 90 days.
The first ninety days of the volunteer experience is mutually probationary.
Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.
I Agree
Continue
