Adult Volunteer Application

Application Date

MonthDayYear

Volunteer Location (please check at least one)

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth

Date

Phone Number

Area CodePhone Number

E-mail

Employment Status

Person to notify in case of an emergency:

Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Work Experience (please provide company names, dates of employment and position)

Do you prefer patient contact?

Do you prefer a special assignment?

If yes, where?

Skills you would like utilized in your volunteer assignment

Availability (please fill in all available times)

Rows	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
9am - 12:30pm
12:30pm - 4pm
4pm - 7:30pm

What do you hope to gain from your volunteer experience at Jefferson?

Personal References (2)

Please complete all information, and family members are not allowed.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Statement of Agreement

I understand that I must be punctual and regular in attendance, helpful in my assignment and careful to honor the confidential nature of what I observe and all other rules and regulations of the Volunteer Services Department. I understand that my service as a volunteer is conditional, based on need and satisfactory service, and may be canceled at any time.

I understand that due to the extensive onboarding process for both the volunteer and Kennedy Health, we require a 6 month, 100 hour commitment before supplying service documentation or supporting application for a paid position at Kennedy.

I certify that the above information is true and correct to the best of my knowledge. I understand any false statement on this application may be considered cause for rejection of this application or for dismissal if such statement is discovered subsequent to an assignment. I agree that if offered an assignment, I will consent to the proper health screenings. I understand continued volunteer service is contingent upon completion of the screening and results.

Date

MonthDayYear

Applicant's Digital Signature

Type Captcha Word to Verify Submission