Volunteer Online

Personal Info

First Name Last Name Address Address 2 City State Zip Home Phone Other Phone Date of Birth

School Info

Name of School Enrollment Full Time Part Time Number of Credit Hours Are you volunteering to complete a school requirement? Yes No If yes, how many hours are you required to volunteer?

Current Employer

Current Employer (If applicable) Job Title Number of hours you work per week: Supervisor Supervisor Phone Number

Previous Volunteer Experience

Previous Volunteer Experience (If applicable) Name of facility (dos) from: (dos) to: Duties

Please list any foreign languages you speak fluently: Are you willing to act as an interpreter? Yes No Please list any other skills or experience:

Have you ever been convicted of a crime, felony or misdemeanor, or do you have a conviction pending? (excluding traffic violations) Yes No If yes, please explain

How did you hear about volunteer opportunities at Thorek? Why do you want to volunteer in a healthcare setting? What type of service/duties would you like to perform at Thorek?

Personal or Professional References

1. Name 1. Phone No. 1. Relationship to you
2. Name 2. Phone No. 2. Relationship to you
3. Name 3. Phone No. 3. Relationship to you

Availability

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays

Emergency Contact Info

Name Relationship Address Phone No. Other Phone No.

By clicking submit below, I agree that to the best of my knowledge all statements set forth in this application are true and accurate. I authorize a full investigation of my references and the statements contained herein. I understand that any misinformation will call for immediate dismissal from my volunteer duties at Thorek Memorial Hospital. I agree to abide by the policies and rules of Thorek Memorial Hospital with regard to conduct, procedure and decorum. I agree to protect patient confidentiality and uphold the Mission, Vision and Values during my tenure as a volunteer and representative of Thorek Memorial Hospital.