| Date: |
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| Name: |
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| Date of Birth: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Email Address: |
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| Active student? |
Yes No |
| School Attending: |
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| Area of Study: |
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| Languages: |
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| Would you be available for special projects and/or mailouts?
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Yes No |
| Are you wishing to volunteer in order to receive service learning hours or college credit?
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Yes No |
| If so, how many hours are needed/required to complete this requirement? |
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| Work History:
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| Current Employer, Title, Duties: |
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| Previous Employer, Title, Duties: |
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| Volunteer History:
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| Current Volunteer Organization: |
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| Previous Volunteer Organization: |
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| Previous Volunteer Organization: |
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| Hobbies and other interests: |
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| Additional Training or Skills: |
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| How did you find out about us? |
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Your schedule of availability: Please mark the days and hours
you may be available (in general) |
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| Emergency Contact: |
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| Name: |
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| Phone Number: |
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| Relationship: |
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| Reference One(Non-family): |
| Name: |
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| Phone Number: |
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| Relationship: |
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| Reference Two (Non-family): |
| Name: |
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| Phone Number: |
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| Relationship: |
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If your name has changed in the past seven years, please indicate your
maiden or former married name(s) |
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| Current street address: |
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| City: |
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| State: |
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| Zip: |
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| Length at this address: |
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| Former street address: |
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| City: |
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| State: |
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| Zip: |
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| Length at this address: |
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| Former street address: |
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| City: |
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| State: |
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| Zip: |
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| Length at this address: |
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Huntsville Hospital is an Equal Opportunity Employer. As such, Huntsville Hospital pledges to take action to preclude discrimination in recruitment, training, discipline, and/or termination of volunteers because of race, color, creed, age, sex, national origin, disability, veteran status or other reason in accordance with all applicable state and federal statutes, executive orders, and regulations which prohibit discriminatory personnel practices. I certify that the information given on this application and in any other supporting documentation, resume, etc., is true and correct. I understand that any false information given; willful or negligent misrepresentation made; or failure to disclose any requested information during the course of application to volunteer at Huntsville Hospital may result in termination.
I hereby authorize Huntsville Hospital and/or its agents to make an independent investigation of my background, references, character, professional competence, ethics, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained in the application package and/or obtaining other information which may be material to my volunteering at Huntsville Hospital. I hereby authorize my prior employers (for both paid and unpaid work), to release any requested information from my personnel files. I release Huntsville Hospital and/or its agents and any person or entity, which provides information pursuant to this authorization from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all information is true and correct to the best of my knowledge.
The Volunteer Service Department is not obligated to provide a placement, nor are you obligated to accept the position offered. I understand that Huntsville Hospital reserves the right to make any scheduling changes at any time to include shift, hours and duties.
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Huntsville Hospital will not release your address or information.
Any questions? Please call 265-8013.
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