St. Francis Volunteer Application

(* denotes required information)  

Personal Information
* Name  
* Street Address  
* City  
* State  
* Zip Code  
* Phone Number  
* Email Address  
* Birthdate  
Are you a  
U.S. citizen?  		 yes  no

Occupation Information
Present Occupation  
Employer  
Phone Number  
Education and Training  

Volunteering History
Volunteer Experience  
Have you ever  
worked or volunteered  
in a healthcare setting?  		 yes  no
If yes, please describe  

Contact for Medical Clearance
* Your Physician's Name  
* Street Address  
City  
State  
Zip Code  

Personal History
Have you ever been  
convicted of a crime?  		 yes  no
If yes, please describe  
Have you ever had  
a discharge from  
any military service?  		 yes  no
If yes, please describe  

Personal Interests
Hobbies,  
special interests,  
organizations  
(church, civic, etc.)  

Personal Reference #1 (other than family)
* Name  
* Street Address  
* City  
* State  
* Zip Code  
* Phone Number  

Personal Reference #2 (other than family)
* Name  
* Street Address  
* City  
* State  
* Zip Code  
* Phone Number

Availability to Volunteer
Days available  
(check all that apply)  		 Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times available   morning
afternoon
evening
weekly
biweekly
monthly
 
Desire to Volunteer
Why do you wish  
to volunteer  
at St. Francis?  
Do you have a  
preference as to where  
you volunteer?  		 yes  no
If yes, where  
 
Emergency Notification
Notify in case of emergency:
* Name  
* Relationship to You  
* Street Address  
* City  
* State  
* Zip Code  
* Home Phone  
* Business Phone  

I certify that answers given here are true and complete to the best of my knowledge.

I hereby give St. Francis permission to contact the listed references, physician, and to conduct a drug screening or criminal check if appropriate.

A health assessment and safety training are required by the hospital. I understand that volunteer placement is contingent upon completing all initial and future health requirements and training as required by Bon Secours St. Francis Health System.

* I agree with the above statements.