Volunteer Application Form

Thank you for your interest in volunteering at Centerpoint!

Please complete and submit this application to Sarah Peterson, HR Manager. Once the application is received there will be an interview to determine if there are current openings in areas which appear to match your interests and availability. If accepted to volunteer service, applicants are required to: (1) complete a lab screening for tuberculosis and titers: paid for by the hospital, (2) have a background check: paid for by the hospital, and (3) complete 1 day of hospital orientation. All volunteers are asked for at least a 4 hour a week volunteering commitment.

All fields with an asterisk (*) are required.

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Fields

Applicant information

Name*

First Name*

Last Name*

Address*

Address Line 1

Address Line 2

City

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State

ZIP Code

Home Phone

Cell Phone

Email

Best time to contact you:

Are you at least 18 years of age?

Yes No

Birth Date

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Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

In case of emergency, please notify:

Relationship

Daytime phone number(s)

Education and experience

Formal education or training

Currently or plan to be a student in college/nursing program?

Yes No

What school?

Professional certification

Current employer and address

Supervisor name

Employer phone

Previous occupations

Have you ever been convicted of a crime?

Yes No

If yes, please explain when, where, and disposition

I have volunteered at Centerpoint, Independence Regional, or Medical Center of Independence previously:

Yes No

Why do you want to volunteer?

Previous volunteer experience:

Organization

Supervisor

Type of service performed

Date

Address and phone number

Organization

Supervisor

Type of service performed

Date - Copy

Address and phone number

Have you ever been terminated from employment or volunteer service? Yes No

If yes, please explain:

References

Name

First Name

Last Name

Phone

Address

Name

First Name

Last Name

Phone

Address

Name

First Name

Last Name

Phone

Address

Available time for volunteering (please check all time that apply)

Sunday Morning Sunday Afternoon Sunday Evening Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening Saturday Morning Saturday Afternoon Saturday Evening

Applicant acknowledgment

I certify that the information given by me in this application is true and complete. I hereby authorize all individuals and organizations named or referred to in this application to give Centerpoint Medical Center all information relative to my possible volunteer assignment and work habits. I hereby release such individuals, organizations and Centerpoint Medical Center from any liability for any claim, damage, which may result. I understand that I will not be paid for time volunteering at Centerpoint.

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