Volunteer Student Application 2020 Personal InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last NicknameEmail* 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, part timeNoPlace of employment*Work phoneEducation or special skillsHobbiesOther volunteer workHealthHealth statusExcellentGoodFairDo you have any chronic physical or medical conditions which might limit your ability to volunteer?*YesNoIf yes, please explain*EducationSchool*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.*ClassGrade Emergency 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*RelationshipReference 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:* 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*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmMonday availability*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmTuesday availability*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmWednesday availability*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmThursday availability*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmFriday availability*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmSaturday availability*Early mornings, 6-8amMornings, 8am-NoonAfternoons, Noon-4pmEvenings, 4-6pmEvenings, 6-8pmHow 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 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 NameThis field is for validation purposes and should be left unchanged.
