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Community Health Center of Branch County

Volunteer Application

The following form is for consideration to be a volunteer at Community Health Center of Branch County. Your request will be processed and someone will contact you soon.
Answer the questions to the best of your knowledge and agree to the statement at the end of the form. We appreciate your interest.
* Name
Please provide your full, legal name.
* Date
Please provide the current date of application submission. 00/00/0000
* Address
Street Number and Name
City, State Zipcode
  Email Address
* Phone #
Please provide your work and home phone numbers.
* Emergency Contact
Please provide a name, phone and relationship of an emergency contact.
* Birth Date (Must be atleast 15 years old)
example 00/00/00
* Volunteer Type: Adult     Teen    
* How were you referred to the Volunteer Program at CHC?
  If you selected organization, please provide the name.
  If you selected church, please provide the name of the church.
Volunteer Work Objectives: Please select all that apply
* Objectives
Please type all of the objectives that correspond to your current objectives. Suggestions include: learn new skills, use skills, develop skills, help the community, meet and work with people, make worthwhile use of free time, explore career options, other (please explain).
Education
* Grade
Please select the grade level you have completed.
  Education
If other, please provide the grade you completed.
Experience
Please list paid employement and most recent jobs first.
  Organization Name
Please provide the company or organization name where you were most recently employeed.
  Job Title
  Job Duties
  Length of Service
  Organization Name
Please provide the name of the organization you worked at before the above organization.
  Job Title
  Job Duties
  Length of Service under 1 year     1-5 years     over 5 years    
  Current Occupation Employeed     Retired     Student     Homemaker     Looking for work    
Volunteer Experience
  Organization
  Job Title
  Job Duties
  Length of Service Under 1 year     1-5 years     Over 5 years    
  Organization
  Job Title
  Job Duties
  Length of Service Under 1 year     1-5 years     Over 5 years    
Other Information
* Are you required to volunteer? Yes     No    
  If so, by whom?
  Do you have any impairments (physical, mental, or medical) which would interfere with your ability to perform volunteer assignments as requested? Yes     No    
  If yes, briefly explain.
  To help us better dertermine a challenging, rewarding, and enjoyable volunteer position for you, please indicate your personal interests and hobbies:
References
Please provide us with the names and phone numbers of two NON-FAMILY, adult references who would be willing to respond to a reference request (neighbor, minister, employer, teacher):
* Name
* Phone
* Relationship
Must be an adult and non-family member
* Name
* Phone
* Relationship
Must be an adult and non-family member
Availability
What type of time committment would you make if you became a CHC volunteer?
  Please list days you would be available to volunteer as well as whether you could volunteer in the morning, afternoon, or evening.
* Total number of hours per week you would like to volunteer:
Skills
  Please type your skills in the box below.
Suggestions include: caregiver, computer, telephone, mailings, bookkeeping, cash register, sales, writing, audio/visual, public speaking, sign language, working with public, sewing/knitting/crocheting, forenign language.
Placement Preferences
  Please type in the area below, what areas you'd like to volunteer in:
Suggestions include: Cafeteria, Cancer Center, Dietary, Emergency Room, Gift Cart, Gift Shop, Information Desk, Sewing/Knitting/Crocheting, Maintenance/Grounds, Messenger Service, Office/Clerical, Patient Care Units, Radiology, Tour Guide, Union City Clinic.
* Disclosure Statement
I certify that the responses on this document are true to the best of my knowledge. I agree that this information may be certified and references contacted by CHC Volunteer Services. Misrepresentation of facts constitutes cause for separation from CHC Volunteer Services. Please verify by typing your initials below.