Deaconess - Foundation

Thank you for your interest in the Auxiliary and/or volunteer opportunities at Deaconess. Please inform the Volunteer Services/Community Relations Department if you need assistance during the application process. This application may not be considered unless completed in full. The submission of this application does not automatically result in an interview or an offer to join the Auxiliary and/or Volunteer Services.

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PERSONAL INFORMATION

Last Name:

First Name:

Middle Name:

Street Address:

City:

State:

ZIP:

Phone:

Email:

Are you over the age of 18?:

Yes
No

AREAS OF INTEREST
(Check All That Apply)

Other (Please List Area of Interest):

Location Preferred (Check All That Apply):

Gateway
Midtown

AVAILABILITY

Can you commit to volunteering a minimum 50 hours per year?: (Most assignments are 2-4 hours per week, and many volunteers do not volunteer during the months of June and July.)

Yes
No

Days and Hours Available:

BACKGROUND

Current Employer:

Enter N/A if you are not currently employed

Business Address:

Enter N/A if you are not currently employed

Dates of Employment:

Enter N/A if you are not currently employed

Occupation:

Enter N/A if you are not currently employed

Prior Volunteer Experience:

Enter N/A if this question does not apply to you

Special Training, Skills or Abilities :

Have you been convicted of a crime, excluding minor traffic violations?:

Yes
No

If yes, please list the citation, date, court and place where the offense occurred:

Please Note: A conviction does not necessarily disqualify you from consideration. Please explain offense thoroughly so that an informed decision and placement can be determined.

Why would you like to volunteer at Deaconess?:

How did you hear about the Volunteer Program?:

REFERENCES
(Individuals who have known you for at least a year and are not a relative.)

First Reference

Name:

Address:

Phone:

Email Address:

Years Known:

Second Reference

Name:

Address:

Phone:

Email Address:

Years Known:

Third Reference

Name:

Address:

Phone:

Email Address:

Years Known:

Please note additional information will be required to process your application, including social security number, date of birth, health history, immunizations, etc.

Please read carefully and sign:

I voluntarily authorize Deaconess to make a thorough pre-selection investigation, including a criminal history background check. I understand that I have the right to obtain a copy of that report at my own expense and to challenge any information in it that I believe to be inaccurate. I hereby authorize former and present individuals/organizations/companies to provide or verify any information they have regarding me, my employment, or my membership in any group listed in this application and release them from any liability for furnishing such information to Deaconess. I understand that my selection is contingent on satisfactory outcomes of reference and background checks. I further understand that as a volunteer I am not eligible for and have no expectation of receiving compensation or benefits.

All information in this application is true and complete. I understand that if I am selected, false statements on this application and post-selection documents shall be considered sufficient cause for dismissal. If selected, I agree to abide by the policies, procedures, and rules of Deaconess and the Volunteer Services/Community Relations Department. I further agree to protect the confidentiality and privacy of any information regarding Deaconess, its patients, its employees, and fellow volunteers.

Electronic Signature:

/For You/Donors and Volunteers/Volunteer/Volunteer Application Form