Volunteer Adult Application 2020 Personal InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Any other names by which you have been known. Including maiden name.Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phone*Cell phoneDate of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HistoryAre you employed?*Yes, full timeYes, part timeNoRetiredPlace of employment*Work phoneHave you ever been employed by Mercyhealth?* Yes No If yes, please describe your position and dates of employment at Mercyhealth.Education or special skillsVeteranNoYes-Air ForceYes-ArmyYes-Coast GuardYes-MarinesYes-NavyHobbiesOther volunteer workHealthHealth statusExcellentGoodFairDo you have any chronic physical or medical conditions which might limit your ability to volunteer?*YesNoIf yes, please explain*BackgroundHave you ever been convicted of a crime, including misdemeanor and felony?*YesNoIf yes, list offense.Applicants are not required to disclose sealed or expunged records of convictionEmergency ContactPlease list the emergency contact we should call on your behalfName First Last Home phoneCell phoneWork phoneRelationshipReferencesList three people not related to you who can attest to your character. Please list complete mailing address or Email address.Reference OneName* First Last Email* Phone*Relationship*Reference TwoName* First Last Email* Phone*Relationship*Reference ThreeName* First Last Email* Phone*Relationship*Why do you want to become a Mercyhealth volunteer?*AvailabilityI am interested in volunteering at:* Mercyhealth Javon Bea Hospital and Physician Clinic-Riverside Mercyhealth Javon Bea Hospital-Rockton Mercyhealth Hospital and Trauma Center-Janesville Mercyhealth Hospital and Medical Center-Harvard Mercyhealth Hospital and Medical Center-Walworth Please indicate the days you would be available to volunteer.* Select All Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday availability*MorningAfternoonEveningsAll DayMonday availability*MorningAfternoonEveningsAll DayTuesday availability*MorningAfternoonEveningsAll DayWednesday availability*MorningAfternoonEveningsAll DayThursday availability*MorningAfternoonEveningsAll DayFriday availability*MorningAfternoonEveningsAll DaySaturday availability*MorningAfternoonEveningsAll DayHow often are you able to volunteer? (minimum requirement is two shifts per month)*Once a weekTwice per weekTwice per monthCommitment and ObligationWhat length of commitment are you willing to make?*Long-termSeasonalWill this volunteer position fulfill an obligation for community service?*YesNoIf so, list community service and how many hours are required for this assignment?*ConsentBy checking this box, I authorize the Volunteer Services Department at Mercyhealth Hospital to do a criminal background check and to contact my references. I release all parties from liability for seeking or furnishing such information.* Yes I agree By checking this box, I acknowledge that all of the above information is true, correct and complete. I understand a false answer to any question on this application is grounds for termination or the application process, or dismissal from Mercyhealth's Volunteer Program.* Yes I agree PhoneThis field is for validation purposes and should be left unchanged.
