Personal Information

Person to Notify in Case of Emergency

Employment and/or School Information

Volunteer History, Work Experience, Special Interests, Hobbies, Skills, Training

Volunteer Areas of Interest

Check the box of all activities that interest you in each category

Personal or Professional References

First Reference

Second Reference

I authorize the above persons to supply the requested information in the reference check for my application as a volunteer. I release the aforementioned from all liability in providing this information and in verifying the information that I have provided through the application process

I certify that all of the information supplied is accurate.

I wish to donate my services and understand there is no payment for services rendered under the Volunteer program. I understand that photographs may be taken from time to time for publications or other uses.

If accepted as a volunteer, I agree to serve according to regulations, policies and procedures of CHI Health at Home. I will respect patient rights and maintain confidentiality concerning patients and families and will not discuss confidential information that I might obtain through my volunteer assignments.