Application

Application

Required fields are marked with a

Name
Last
First
Middle
Address
City
Zip
Telephone No. (home)
Telephone No. (work/cell)
E-mail address
Education
Highest level of education completed:
Special Skills or Training

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Professional Licenses and/or Certifications

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Work Experience
Job Title or Position
Kind of Business
Duties

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Job Title or Position
Kind of Business
Duties

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Hobbies or Special Interests

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Do you have a history of the following?
Heart disease or heart attack
Rapid, slow or irregular heartbeat
Stroke
High blood pressure
Varicose veins, blood clots
Shortness of breath
Emphysema
Asthma
Tuberculosis
Jaundice, hepatitis
Epilepsy, seizure disorder
Fainting spells, dizziness
Parkinson's Disease
Arthritis, painful or swollen joints
Back problems or back surgery
Hernia (rupture)
Diabetes
Comments:

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I have read the above information and acknowledge the answers to be true and correct to the best of my knowledge. I agree to work within the guidelines of the volunteer program and to protect the right of confidentiality of all patients and staff.
As a volunteer, my services are rendered on a gratuitous basis.
Signed (type name)
Date
Volunteer Experience

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Reason for Volunteering

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Type of Service Preferred
Days of Week Preferred
Work Hours Preferred
Are you willing to be called for temporary assignments in addition to your regular volunteer service?

yes

no

Person to be contacted in case of accident or illness:
Name
Address
Telephone
Relationship
Health Questionairre
Please give the name of your family physician:
Are you presently under the care of a physician?

Yes

No

If yes, please explain:

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Is your physical activity limited in any way?

Yes

No

If yes, please explain:

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Do you take any medications on a regular or as needed basis?

Yes

No

If yes, please explain:

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