Volunteer Application
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Applicant Status:
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New
Returning
If returning, when did you volunteer last?
Contact Information
Full Name
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First Name
Last Name
E-mail:
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cellular Phone Number
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Area Code
Phone Number
Home Phone Number
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Area Code
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School
Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Area Code
Phone Number
Availability and Duration
Please select the program you are applying for
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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:
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High School (Must be able to work a 4-hour shift weekly. Minimum 20 hrs. total.)
College (Must be able to work a 4-hour shift weekly. Minimum 40 hrs. total.)
Post-Graduate (Must be able to work a 4-hour shift weekly. Minimum 40 hrs. total.)
One Day Observation Only (2 hours)
Do you have a volunteer hours requirement for a class or program?
Yes
No
If so, how many volunteer hours are you requesting?
Volunteer Programs
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Fall: September - December
Spring: January - April
Summer: May - August
Clinic Requesting (First Choice):
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Kailua
WORC
Honolulu
Aquatic
Clinic Requesting (Second Choice):
Kailua
WORC
Honolulu
Aquatic
Please indicate which days and shifts you are available to work. Morning (8:00am - 12:00pm) or Afternoon (1:30pm - 5:30pm).
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Morning: 8:00am - 12:45pm
Afternoon: 1:45pm - 6:15pm
No Shifts
Monday
Tuesday
Wednesday
Thursday
Friday
Have you ever been convicted of a crime?
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No
Yes
Other
How did you learn about our Volunteer Program?
Website
Relative / Friend
F&L Employee
Returning Volunteer
Other
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
Are you requesting this placement to satisfy the hourly requirements for the UH Manoa course KRS 488?
Please Select
Yes
No
Program supervisor:
Supervisor Phone Number
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Area Code
Phone Number
References
Please list two references that can recommend you for volunteer service. (Non-family members)
Reference 1 Name
Relationship
Phone Number
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Area Code
Phone Number
Reference 2 Name
Relationship
Phone Number
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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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