VOLUNTEER APPLICATION - The Chester County Hospital

VOLUNTEER APPLICATIONPersonal Information:Mr. / Mrs. / Ms. _________________________________________________________________Home #: __________________ Work #: ___________________Mobile #:__________________Email: _______________________________________________ Birth Date:_________________Address: _______________________________________________________________________City: ___________________________________State: __________ Zip: ___________________Emergency Contact: _____________________________________________________________Phone __________________________________________ Relationship______________Are you currently: ___Employed ___Retired ___Other _______________________________Are you currently: ___College Student ___High School Student Graduation Year: ________Name of your school/college ________________________________________________Other ___________________________________________________________________Education: __________________________________________________________________________________________________________________________________________Employment: (Please list your most recent employment experience.)Employer __________________________________________ From _______ To _______Occupation ______________________________________________________________Volunteer Experience: (Please list your most recent volunteer experience.)Agency ___________________________________________ From _______ To _______Responsibilities ___________________________________________________________Other Volunteer Experiences ________________________________________________What is your availability to volunteer at The Chester County Hospital?___________________________________________________________________________________________Please bring this form with you to The Chester County Hospital 8848‐012Attn: Volunteer Services Department, 701 East Marshall Street, West Chester, PA 19380 09/20101 of 2

How did you learn of the volunteer opportunities at the Hospital?_______________________________________________________________________Do you have any special skills, talents and/or hobbies that you would be willing to share aspart of your volunteer service? If yes, please elaborate.______________________________________________________________________________________________________________________________________________Are you a member of The Women’s Auxiliary to The Chester County Hospital? ___Yes___ NoIf yes, which one? _________________________________________________________Have you ever been convicted of a felony? ___ Yes ___NoIf yes, please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________Two References (not relatives):1. Name ________________________________________________ Phone # ________________Address _________________________________________________________________Years Acquainted _________________________________________________________2. Name ________________________________________________ Phone # ________________Address _________________________________________________________________Years Acquainted _________________________________________________________I hereby authorize persons, previous employers and organizations named in this application to provide thisfacility with any relevant information. I release all such persons from any liability regarding the use of thisinformation. I understand and will abide by the rules and regulations including, but not limited to uniform,medical statements, training requirements, and privacy regulations of The Chester County Hospital.Signature _______________________________________________________Date ___________FOR COURT ORDERED HOURS ONLY:OFFENSE _______________________________________________________________________Number of hours needed_______________________________Deadline____________________PROBATION OFFICER _____________________________________________________________Please bring this form with you to The Chester County Hospital 8848‐012Attn: Volunteer Services Department, 701 East Marshall Street, West Chester, PA 19380 09/20102 of 2