Volunteer Application

Personal information

Name*

First Name

Middle Name (optional)

Last Name

Preferred nickname

Date of birth*

Address information

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is anyone else at this address already a volunteer at Catholic Medical Center?

Yes No

Please list the individual's name

Are you currently employed at Catholic Medical Center?*

Yes No

Have you volunteered for this organization before?*

Yes No

What year/department?

Contact information

Email*

Phone*

Best time of day to reach me

Emergency contact name*

Emergency contact relationship*

Emergency contact phone*

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

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.

Yes No

A conviction will not necessarily disqualify an applicant for volunteer service.

Please explain

Education

High school graduate?

Yes No

College/Graduate school degree?

Yes No

Major/degree

Employment information

I am*

Employed full time Employed part time Unemployed Retired Student

Current employer or school

Current occupation

Work schedule information

What days do you work?

What hours do you work?

Previous employer or work experience

Past or present volunteer experience

General information

What has prompted you to want to volunteer at this time?

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

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

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

How did you find out about our volunteer program?

I attended a Catholic Medical Center event I was a patient at Catholic Medical Center Catholic Medical Center website I called Catholic Medical Center I was referred by someone I am a current/former employee of Catholic Medical Center

Who were you referred by?

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 campus 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

Commitment

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

Yes No

Availability

Other information

Date you can begin volunteering

Please email the following vaccine information to Pamela.Kanavos@hcahealthcare.com:

Proof of COVD-19 vaccination
Proof of Influenza (Flu) vaccination

References

Please provide two personal references (other than relatives), who have known you for more than one year and who would be willing to serve as references.

Reference 1 name*

Reference 1 phone*

Reference 1 email*

Reference 2 name*

Reference 2 phone*

Reference 2 email*

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.

General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)

Volunteer application

Become a part of our caring community

Thank You

Personal information

Address information

Contact information

Education

Employment information

Work schedule information

General information

Commitment

Availability

Other information

References