Volunteer Application

Family House Volunteer

Application Form
Family House provides a “home away from home” for patients and their families who must travel to Pittsburgh for medical care.

Please fill out the application below if you would like to become a House Volunteer. Weekly Volunteers are scheduled for one 3-4 hour shift weekly or bi-monthly, and must be able to commit to at least six months of service. "Floater Volunteer" shifts are available if you cannot make a regular commitment.
Personal Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Family House?*
Community Affiliations (if any):
Skills, Interests, and Hobbies:*
Which of the following volunteering activities interest you?*
Background
Education Completed*

High School or EquivalentCollege GraduateSome College or Technical SchoolOther
Are you currently employed?*

Yes, full-timeYes, part-timeNoStudentRetired
Current or Previous Employer
Occupation
Do you have any volunteering experience? If yes, please describe.*
Availability

Please indicate your general availabilities for volunteering on a weekly basis - check as many blocks as your schedule permits. Specific dates and times will be discussed during your interview.*

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning (11:30am-3:00pm)
Afternoon(3:00pm-6:00pm)
Evening(6:00pm-9:00pm)

What is your earliest start date?*

MonthDayYear
Date
Additional notes about your schedule
Criminal Background Information

In answering the following question, do not disclose convictions that have been expunged, sealed, or statutorily eradicated; misdemeanor convictions for which probation has ben successfully completed or discharged and the case has been judicially dismissed; or any referrals to a pre-trial or post-trial diversion program.
Have you ever been convicted of or pled guilty to a felony?*

YesNo
Have you ever been convicted of or pled guilty to a misdemeanor that might be related in some way to the position for which you are applying (including convictions relating to honesty, integrity, or illegal use of drugs)?*

YesNo
If you answered "Yes" to either of the above questions regarding convictions, please describe the conviction(s) in detail, including dates:
Agreement
The statements I have made on this form are true and correct to the best of my knowledge. I understand any omission of facts by me is cause for immediate dismissal.I understand that I am volunteering my time without contemplation of compensation or employment and given with humanitarian, religious, or charitable reasons.I release Family House and its operating divisions and agents from any and all claims, causes of action, and liabilities arising out of any and all investigation, background checks, and verification of the information I have provided and its determination of any qualifications and abilities.I understand that, if accepted as a volunteer, I will be required to abide by all of the policies, rules, and regulations of Family House.
Date*

MonthDayYear
Date
Signature*

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Family House Volunteer

Personal Information

Background

Availability

Criminal Background Information

Agreement