Volunteer Application | Catholic Medical Center

I certify that all the information that I provide on this volunteer application and in any interview will be complete, true and accurate. I understand that if any such information is later found to be incomplete, false or misleading in any way it may be considered sufficient cause for termination of my volunteer service. I agree that Catholic Medical Center and any of the references provided on this application, may exchange information regarding my qualifications without incurring any liability whatsoever for supplying such information. I understand that I will not be paid for my services as a volunteer. I agree to abide by all organization and volunteer policies. I understand that CMC is not obligated to provide volunteer placement, nor am I obligated to accept the volunteer assignment offered.

Please note: Volunteer placement is subject to:

Satisfactory reference reports and criminal record check
Satisfactory medical history review and required testing.
Personal interview with the Manager of Volunteer Services, and/or department staff as required.
Ability to make the required minimum time commitment
Willingness to abide by all hospital requirements and regulations.

My typed name below shall have the same force and effect as my written signature.

Signature of Applicant:

Qualified applicants shall receive consideration regardless of race, religion, color, creed, national origin, sexual orientation, age, disability, marital status or any other legally protected status.

Title

Mr Mrs Ms Dr Other

Other Title:

Last Name:

First Name:

Middle Name:

Preferred Nickname:

Date of Birth:

Street Address:

Apartment Number:

City:

State

ZIP:

Is anyone else at this address already a volunteer at CMC

Yes No

If yes, please list the individual’s name:

Are you currently employed at CMC

Yes No

Have you volunteered for this organization before

Yes No

If yes, what year/department:

Email:

Cell Number:

US Phone number:

I prefer to receive calls at

Cell Home Other

Best time of day to reach me:

Emergency Contact

Name:

Relationship:

Telephone:

Do you have any medical conditions that would affect your ability to perform your volunteer duties, or that the volunteer office should be aware of

Yes No

If yes, please explain:

Have you ever been convicted of a felony or misdemeanor or narcotics violation? Arrests or charges that have been expunged need not be disclosed. A conviction will not necessarily disqualify an applicant for volunteer service.

Yes No

If yes, please explain:

High School Graduate

Yes No

College/Graduate School Degree

Yes No

Major/Degree:

I am

Employed Full Time Employed Part Time Unemployed Retired Student

Current Employer or School:

Current Occupation:

What days do you work:

What hours do you work:

Previous employer or work experience:

Past or present volunteer experience:

Extracurricular activities:

What has prompted you to volunteer at this time:

If you are familiar with our Volunteer Program, please indicate your top area of interest:

What types of volunteer duties or activities would you like to be involved with:

What skills and experience would you like to share in your role as a volunteer:

How did you learn about our volunteer program?

CMC newsletter I attended a CMC event I was a patient at CMC CMC website I called CMC I was referred by someone I am a current/former employee of CMC

Name of the person who referred you:

Relation

Volunteer Employee Friend Family member

General area in which you would prefer to serve

I would like to volunteer at the hospital I would like to volunteer at one of CMC’s off camput Community Programs I would consider a volunteer assignment at either the hospital or a community program

Please provide any additional information that might help us place you in a volunteer assignment, or that you feel would be pertinent to your application:

Are you able to make a minimum commitment of one 3 to 4 hour volunteer shift per week for six consecutive months

Yes No

Sunday

Mornings Afternoons Evenings

Monday

Mornings Afternoons Evenings

Tuesday

Mornings Afternoons Evenings

Wednesday

Mornings Afternoons Evenings

Thursday

Mornings Afternoons Evenings

Friday

Mornings Afternoons Evenings

Saturday

Mornings Afternoons Evenings

Date you can begin volunteering

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