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Volunteer Application

Thank you for your interest in Volunteering.
The information contained on this application will be used to evaluate whether an appropriate placement is available for you within the volunteer services program.

An * indicates a required field.

About You

First Name *
Middle Initial
Last Name *
Date of Birth MM/DD/YYYY *
If you are under the age 18, please provide a parent's name and phone number.
Please list any skills, hobbies or special interests.

Your Contact Information

Address *
Address Line 2 City State Zip Code
Daytime Phone Number *
Email *
Confirm Email Address *

Emergency Contact

Name of Emergency Contact *
Relationship *
Phone Number of Emergency Contact *

Education

Are you a high school graduate? *
Yes No
What is your highest grade completed? *
Are you presently attending a school? *
Yes No
If yes, please name the school you attend and the degree you seek.
High School, College or University
Grade Point Average
Degree
Counselor or Advisor

Employment

Are you currently employed?
Yes No
If yes, complete the following:
Employer
Phone Number of Employer
Position Title and Responsibilities

Volunteer Information

What interests you about volunteering at Saint Francis?
In which area(s) would you like to volunteer?
Please list any previous volunteering experience.
Are you a member of the Saint Francis Junior Board?
Yes No
Are you a member of the Saint Francis Health Careers Exploring Post for high-school students?
Yes No
Have you ever been employed at Saint Francis? *
Yes No
Do you have any relatives working in the hospital? *
Yes No
If yes, in what departments?

Criminal History

Have you ever been convicted of a crime or violation other than a minor traffic infraction? *
Yes No
If yes, please explain.

References

Please list names and addresses of 2 references that are not family members.

Reference 1

Name *
Address
Address Line 2 City State Zip Code
Phone Number *
Relationship *

Reference 2

Name *
Address
Address Line 2 City State Zip Code
Phone Number *
Relationship *
By submitting this form, I authorize Saint Francis Healthcare to verify the information I have provided on this application. I understand that any misstatement, omission or misleading information given in my application or interview may result in the rejection of my application or interview, or the withdrawal of any volunteer offer. I authorize Saint Francis Healthcare to make a thorough investigation and release from all liability and responsibility all person and entities, including my present employer, requesting or supplying information about my education, employment and activities, personal or otherwise. I acknowledge that any employment with Saint Francis Hospital or Franciscan Care Center will be on a 90-day introductory basis. I understand that, if selected as a volunteer, I must abide by all rules and policies of the volunteer services program and that I can be terminated at any time.

Verification

Please enter any two digits with no spaces (Example: 12) *
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