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Athens-Limestone Hospital

Volunteer Application

Athens-Limestone Hospital
Application for Volunteer Services
All information will be treated confidentially.

"The volunteer services department is committed to a policy of equal opportunity for all applicants volunteering in the facility. This policy applies to accepting, training, and assigning volunteers regardless of race, color, religion, national origin, ancestry, sex, marital status, or disabilities. Volunteers with disabilities may be limited in their assignment."
* Last Name
* First Name
* Date of Birth
* Address
* Telephone Number
* Person to Notify in Case of Emergency
* Emergency Address
* Emergency Phone
* Have You Ever Been Convicted of a Felony yes     no    
  If yes, please describe
* Highest Grade Completed in School 9     10     11     12     GED     College 1-2     College 3-4+    
* Names and Locations of Schools Attended
* Do you have any illnesses, injuries, or disabilities that would affect your ability to perform volunteer services yes     no    
  If yes, please describe
* Are you willing to have health tests which may include chest xrays, TB skin test, and appropriate laboratory tests that may be necessary as part of your volunteer services yes     no    
* List any special skills/interests that you feel would benefit you for service as a volunteer
* Please list prior volunteer experience, including Name of Organization, Address, Dates of Service, Position, and Reason For Leaving
* Please list previous employment experience including Name of Employer, Address, Dates of Employment, Position, Reason for Leaving
* May we contact the agencies/employers listed above yes     no    
* Please list a personal reference (Not relatives) Include the Name, Address, and Phone Number
* Please list a 2nd personal reference (Not relatives) Include Name, Address and Phone Number
* Please list a 3rd personal reference (Not relatives) Include Name, Address, and Phone Number
* Days Available
Please indicate any week days or weekends you are available
* Hours Available
Please indicate a.m. or p.m. Volunteers are usually scheduled in 4 hr. shifts, one day a week between the hours of 8 a.m. and 8 p.m.
* Please write a brief statement to explain why you wish to join the volunteer services program
* If accepted as a hospital volunteer, on what date will you be available for volunteer services