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 Phone number*Phone type* Home phone Cell phone Date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HistoryAre you employed?* Yes, full time Yes, part time No Retired Place of employment* Education or special skillsVeteranNoYes-Air ForceYes-ArmyYes-Coast GuardYes-MarinesYes-NavyOther volunteer workBackgroundHave you ever been convicted of a crime, including misdemeanor and felony?* Yes No If 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 phoneRelationship AvailabilityI am interested in volunteering in:* Winnebago County Rock County McHenry County Walworth County House of Mercy Homeless Center, Janesville 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 week Twice per week Twice per month Commitment and ObligationWhat length of commitment are you willing to make?* Ongoing Seasonal Will this volunteer position fulfill an obligation for community service?* Yes No If 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 EmailThis field is for validation purposes and should be left unchanged.
