Volunteer Application
Name __________________________________________ Date of Birth (year optional) __________________
Mailing Address ____________________________________________________________________________
City, State, and Zip Code____________________________ Email address: ____________________________
Home Phone# ________________________ Work/Cell Phone#______________________________________
Reference: (do not use family or household member)
Name _____________________________________________Phone#_________________________________
Address___________________________________________________________________________________
Education and Employment:
Name of school: _____________________________________________ Last grade completed: ____________
Are you presently employed? ____________
Present (or Past) Employer and position held: _____________________________________________________
_________________________________________________________________________________________
Health:
Have you had any recent illnesses? _____________________________________________________________
Do you have any physical limitations we should be aware of? ________________________________________
If yes, please explain ________________________________________________________________________
_________________________________________________________________________________________
Physician __________________________________________ Phone # ________________________________
In case of emergency, please call
Name _________________________________________Phone#_____________________________________
Skills: (check all that apply):
Typing _____ Photocopying _____ Filing _____ Computer: Excel _____ Word Office _____Data entry ______
Telephone: Receptionist ______ญญญ__________ Customer Service _______________ other __________________
Past Volunteer experiences ___________________________________________________________________
State areas you wish to volunteer_______________________________________________________________
Days and times available_____________________________________________________________________
How did you hear about our Volunteer Program? __________________________________________________
Have you ever been convicted of, or plead guilty to, a crime within or outside of the State of Louisiana?
Yes, if yes, please list state(s) and reason(s): ___________________________________________________
Authorizations:
I authorize Opelousas General Health System to solicit all relevant information about this application, and if required criminal background check.
I agree to abide by all OGHS policies set forth in regards to confidentially and the patient’s right to privacy.
I agree to abide by all OGHS policies set forth in regards to the Substance and Alcohol Abuse Policies and understand that I may be subjected to random testing.
I affirm that the information I provided on this application is complete and accurate. I understand that omission of facts or misrepresentations of information on this application are cause for dismissal from my volunteer assignment if discovered after I start volunteering at the hospital.
Signature ___________________________________________ Date ____________________________ |
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