STUDENT VOLUNTEER APPLICATION - NCH Healthcare System

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WORK EXPERIENCE, SKILLS, AND ACTIVITIES: Work Experience: ________________________________________________________________________ Computer Skills: _________________________________________________________________________ Languages: _____________________________________________________________________________ Volunteer Experience/Community Affiliation: _________________________________________________ Recreation/Hobbies: ______________________________________________________________________ VOLUNTEER PREFERENCES: Patient Contact Non-Patient Contact Information/Clerical Are you able to push a wheelchair: Yes No Are you able to be on your feet for four hours: Yes No When are you available to volunteer? Work Shift: Mornings Afternoons Evenings Flexible Work Days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Flexible If you are participating in the program, will you be able to fulfill the requirement of completing at least 40 hours for the summer; volunteering at least three, four-hour shifts a week (circle one)? YES / NO Please detail expected dates of absence such as vacation, summer camp, or other activities: Please describe your mode of transportation: ________________________________________________
BACKGROUND INFORMATION: NCH Healthcare System conducts criminal record checks. Falsification or failure to disclose complete information will disqualify you from volunteer service. A conviction does not necessarily disqualify you from volunteer service. Have you ever been employed by NCH Healthcare System or any of its affiliates in any capacity? Yes / No (circle one) If yes, when hired? If yes, what department? Other than a misdemeanor traffic violation, have you ever been charged with or convicted of any crime? Yes / No (circle one) If yes, please explain and provide the location (county and state): Are you charged with an unresolved criminal charge? (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?) Yes / No (circle one) If yes, explain and provide the location (county and state): Are you currently on probation? Yes / No (circle one) Date Your Signature
Page 1 and 2: Returning student application deadl
Page 3: COUNSELOR / TEACHER’S COMMENTS: P
Page 7 and 8: Confidentiality Agreement I, ______

STUDENT VOLUNTEER APPLICATION - NCH Healthcare System

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