Volunteer Application

Volunteer Application
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Applicant Status: *

New Returning
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Contact Information
Full Name *

First Name Last Name
E-mail: *

Address *

Street Address
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City	State / Province
Postal / Zip Code	Country

Cellular Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
School
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Availability and Duration
Please select the program you are applying for *

Student Observation Program: For high school or college students / graduates interested in learning about the physical therapy profession. No volunteer commitment required. Observation will be one Saturday for 2 hours. Must be 16 years old or older. Parental consent needed if under age 18. Locations available: Kuakini or Kailua Clinic. Volunteer Program: This program is for students or adults interested in pursuing a degree in physical therapy and who need to complete observation hours. Must be at least 16 years old. Parental consent needed if under age 18. The following commitment is required: minimum of 1 shift (4 hours) per week. High school students are asked to complete a minimum of 20 volunteer hours. College students / adults are asked to complete a minimum of 40 volunteer hours.
Type of Student: *
Volunteer Programs *

Fall: September - December Spring: January - April Summer: May - August
Clinic Requesting (First Choice): *
Clinic Requesting (Second Choice):

Please indicate which days and shifts you are available to work. Morning (8:00am - 12:00pm) or Afternoon (1:30pm - 5:30pm). *

	Morning: 8:00am - 12:00pm	Afternoon: 1:30pm - 5:30pm	No Shifts
Monday
Tuesday
Wednesday
Thursday
Friday

Have you ever been convicted of a crime? *

No Yes
How did you learn about our Volunteer Program?

Website Relative / Friend F&L Employee Returning Volunteer
Why are you interested in volunteering at Fukuji & Lum Physical Therapy?
Education / Training
High School
Current Grade / Graduation Year:

Current Grade Graduation Year
College
Years Completed:

Years Completed Major / Degree
Other School
Years Completed:

Years Completed Major / Degree
If you are in a special program for credit, please indicate which program:
Special program supervisor:
Supervisor Phone Number

Area Code Phone Number
References

Please list two references that can recommend you for volunteer service. (Non-family members)
Reference 1 Name
Relationship
Business Name and Address
Phone Number

Area Code Phone Number
Reference 2 Name
Relationship
Business Name and Address
Phone Number

Area Code Phone Number
Volunteer Agreement
- I authorize investigation on all statements contained in this application. I certify that all information provided in this volunteer application is true and complete. I understand that any false information or omission may disqualify me from further consideration and may result in my dismissal if discovered at a later date.
- Acceptance as a volunteer is contingent upon satisfactory references, verification of the information submitted on this application and satisfactory completion of mandatory requirements.
- I give Fukuji & Lum authorization to contact and obtain information from all references and educational institutions and to otherwise verify the accuracy of information contained in this application. I also release from liability the company and its representatives for seeking, gathering and using such information and all other persons for furnishing such information.
- Fukuji & Lum's Volunteer Program is not obligated to provide a placement for me, nor am I obligated to accept the volunteer position offered.
Applicant's Signature

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Parent / Guardian's Signature is required if volunteer applicant is under the age of 18. Your signature indicates approval for your child's participation in Fukuji & Lum's Volunteer Program.

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Volunteer Application

Contact Information

Availability and Duration

Education / Training

References

Volunteer Agreement