Volunteer Handbook - Roper St. Francis Healthcare

Volunteer Program ApplicationRoper St. Francis HealthcareThank you for your interest in the programs sponsored by theRoper St. Francis Healthcare Volunteer Department.Name: ____________________________________________________ Day Phone: ____________Home Address: _______________________________________________________________________________________________________________________________(zipcode)E-mail address_________________________________________________________ (print clearly)Social Security Number: ______________________ Birthday: _________________(day and month)Are you currently employed? Yes NoIf yes, where? __________________________________ Work phone number: ________________Name, address and phone number of emergency contact:Name: _________________________________________ Phone: ___________________________Address: _______________________________________ Relationship to you: _________________Do you have friends or relatives working for Roper St. Francis Healthcare? Yes NoIf “Yes” give their name, relationship and department: ______________________________________Have you worked as a volunteer before? Yes NoIf yes, where? _____________________________________________________________________Days & times you are most available:_______________________________________________________________________________Special skills or talents you have to offer as a volunteer (typing, computer skills, languages etc.)________________________________________________________________________________Availability: Interests and time preferences: ____________________________________________Is there anything we need to consider in placing you in a volunteer assignment? ________________Have you ever been convicted, plead guilty, plead no contender, or forfeited bond to a violation of anyfederal, state, county or municipal law, regulation or ordinance other than motor trafficviolations? Yes NoHonesty is important. If “yes” please list the date and place of offence, the charges and disposition.(The existence of a criminal record does not constitute an automatic bar to volunteer placement):_____________________________________________________________________________Note: Adult volunteers require a Hirease (National Background) check done for security purposes.Are you a citizen of the U.S.A.? Yes NoIf the answer is “No” are you legally permitted to work in the USA? ___________________________