Adult Volunteer Application
First Name
*
Last Name
*
Phone
*
Email
Street Address 1
Street Address 2
City
State
Please Select
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Occupation
Company
Business Address
Work Phone
Previous Volunteer Experience
Previous Experience as a paid employee:
Have you ever been employed by Cape Fear Valley Health System?
Yes
No
Have you any relatives or close acquaintances at Cape Fear Valley Health System?
Yes
No
Do you have any special training?
Yes
No
Are you presently enrolled at a school or university?
Yes
No
How did you hear about the Cape Fear Valley Health System Volunteer Services?
Have you ever been convicted of any criminal offense? A conviction record will not necessarily be a ban on your acceptance as a volunteer. **Examples may include, but should not be limited to: Driving under the influence, worthless checks, assault, driving while license suspended, disorderly conduct, credit card fraud, embezzlement, etc**
*
Yes
No
Indicate with checkmarks facilities/programs with which you would prefer to volunteer:
Cape Fear Valley Medical Center
Highsmith-Rainey Memorial Hospital
Cancer Center
Southeastern Regional Rehab Center
NICU/Cuddler Program
NODA (No One Dies Alone)
Pastoral Care
Behavioral Health Care
Pediatrics
Blood Donor Center
Pet Therapy
CFVHS Outpatient Clinics
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Shifts
Morning
Afternoon
Evening (5:00pm - 8:00pm)
Number of hours you are available to volunteer each week:
What are your reasons for wanting to become a volunteer with Cape Fear Valley Health System?
Work Preferences
No patient contact
Limited patient contact
Heavy patient contact
No visitor contact
Limited visitor contact
Heavy visitor contact
Limited staff interaction
Heavy staff interaction
Blood Assurance Plan
Limited volunteer interaction
Heavy volunteer interaction
Solitary work projects
Assignment with no physical activity
Assignment with limited physical activity
Assignment with much physical activity
Filing, shredding, answering phones, taking messages, and typical office job functions
Light computer data entry
More concentrated computer assignment
Short term special projects
Clerical projects/work
References: To be acceptable can not be your relative and must have known you for at least five years.
Reference 1
*
First Name
Last Name
Reference Relationship:
*
Reference Phone:
*
Please enter a valid phone number.
Reference 2
*
First Name
Last Name
Reference Relationship:
*
Reference Phone:
*
Please enter a valid phone number.
Reference 3
*
First Name
Last Name
Reference Relationship:
*
Reference Phone:
*
Please enter a valid phone number.
Please Read and Submit
I hereby certify that the information given in this application is fully and correctly answered. I understand that any misrepresentation, omission or misstatement, whether intentional or not, is grounds for rejection of my application or termination of my volunteer status if such an occurrence is discovered at a later date. If, in the judgement of the Health System, any information contained herein is found to be untrue, incorrect, or incomplete, I may be refused acceptance as a volunteer or subject to dismissal if already a volunteer. I voluntarily authorize Cape Fear Valley Health System to investigate all information contained in this application. I authorize my present and former employer and/or three references listed on my application to release any information pertaining to my work record and performance to Cape Fear Valley Health System, and release those employers and references from liability unless such information is provided with knowledge that it is false.I understand that the first fifty hours of volunteer service will be considered as a period of probation. I agree to submit to any physical examination as required by the Health System and, if accepted as a volunteer, I agree to abide by all present and subsequently issued or revised Health System and Volunteer Department policies.I understand that a criminal check will be conducted.I further understand that I may be dismissed as a volunteer with or without cause or with or without notice at anytime, at the option of either the Health System or myself. I understand that no representative of the Health System has authority to enter into an agreement with me for volunteer service for any specified period of time, or to make any agreement with me contrary to the foregoing.Finally, I understand that my application will remain active for no longer than three months from this date, and should I desire to be considered for volunteer service thereafter, I must reapply in the same manner.Cape Fear Valley Health System is an Equal Opportunity/Affirmative Action Employer. All decisions to accept individuals as volunteers are based on individual qualifications without regard to race, color, sex, national origin, age, religious belief or disability.
Submit
Should be Empty: