Volunteer Application

Volunteer Application

First Name

Last Name

Date of Birth (MM/DD/YY)

Address

Address 2

City

State

Zip

Home Phone

Cell Phone

E-mail

Contact Preference

Educational Background

School

Dates Attended

Major Course of Study/Degree

Are You a Current Student?
YesNo

If yes, will you receive credit for your volunteer hours?
YesNo

Employment/Volunteer Background

Dates Employeed

Organization

Type of Work

Paid / Volunteer

PaidVolunteer
PaidVolunteer
PaidVolunteer

Current Professional Registration/License

Have you ever been convicted of a felony?
YesNo

If Yes, please explain

Please provide all medical information we should know (allergies,special medications, instructions, &/or conditions)

Emergency Contact

Phone

What type of work would you like to perform at CHC? Please check all that apply
ClericalMedical RecordsR.N.CleaningAdministrativeComputer/Data EntryL.P.N.MaintenanceReceptionistMedication AssistanceM.A.Fundraising/DevelopmentMailingsCommunity ProgramsEventsWomen's Heath AdvocateMarketing/P.R.
Other

We ask for a 6 month commitment for all volunteer roles

What skills, training, or knowledge do you hope to utilize at CHC?

Bilingual?
YesNo

If yes, which language(s)

Why do you want to volunteer at CHC?

Where did you hear about CHC?

References

Name

Phone

Relationship

Availability

Times

Day(s)

How often per week/month?

How long can you commit to this service?

When are you available to start?

At Catherine's Health Center, it is our mission to provide health education, screening, and primary care medical services to low income, underinsured, and medically underserved residents of Grand Rapids, MI. As a volunteer at CHC, I will be required to follow all personnel policies and rules of the organization.

I have completed this volunteer application and hereby declare the information provided to be accurate and complete to the best of my knowledge.

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