Volunteer Student Application

Personal Information

Name*

Prefix First Middle Last

Nickname

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Home phone*

Cell phone

Date of birth*

History

Are You Employed?*

Yes, part time
No

Place of employment*

Work phone

Education or special skills

Hobbies

Other volunteer work

Health

Health status

Do you have any chronic physical or medical conditions which might limit your ability to volunteer?*

Yes
No

If yes, please explain*

Education

School*

Please list all classes which you attended last semester and grades. You will need to provide us with a copy of your grades to indicate that you are enrolled in a State of Illinois educational program.*

Class	Grade

Emergency Contact

Please list the emergency contact we should call on your behalf

Name

First Last

Home phone

Cell phone

Work phone

Relationship

References

List three people not related to you who can attest to your character. Please list complete mailing address or Email address.

Reference One

Name*

First Last

Email*

Phone*

Relationship

Reference Two

Name*

First Last

Email*

Phone*

Relationship*

Reference Three

Name*

First Last

Email*

Phone*

Relationship*

Why do you want to become a Mercyhealth volunteer?*

Availability

I am interested in volunteering at:*

Select All
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*

Monday availability*

Tuesday availability*

Wednesday availability*

Thursday availability*

Friday availability*

Saturday availability*

How often are you able to volunteer? (Minimum requirement is two shifts per month)*

Once a week
Twice per week
Twice per month

Commitment and Obligation

What length of commitment are you willing to make?*

Long-term
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?*

Consent

By checking this box, I authorize the Volunteer Services Department at Mercyhealth Hospital 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

Name

This field is for validation purposes and should be left unchanged.