Volunteer Application

Volunteer Application

for Greene Care Clinic
Volunteer Position Interest
Name

First NameLast Name
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Email
example@example.com
Best Way to Contact You
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Lived at This Location
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Lived at This Location
Are you unemployed, employed or retired?
Current or Past Employer
Position / Title
Years at This Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Employer
Position / Title
Special hobbies, skills, training that may help the clinic?
Please describe your prior volunteer experience (include dates)
Why do you want to volunteer with Greene Care Clinic?
As a volunteer in a health care facility, you may have close contact with patients and sensitive medical and personal information. For that reason we need to ask the following:
As an adult, have you ever been convicted of a crime (conviction of a crime is not an automatic disqualification for volunteer work)
Date of Offense

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nature of Offense
Disposition
Do you have a current driver's license?
Please list three people who know you well and can attest to your character, skills, and dependability. Include your current or last employer.
Reference #1: Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Length of Relationship
Reference #2: Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Length of Relationship
Please read the following carefully before signing this application.

I understand that this is an application for and not a commitment or promise of volunteer opportunity.

I certify that I have provided information in this application that is accurate and complete to the best of my knowledge. I have also not withheld any information that will unfavorably affect my application for a volunteer position. I understand that information contained on this application will be verified by the Greene Care Clinic and a more detailed background check may be done. I understand that misrepresentations or omissions may be the cause for immediate rejection as an applicant for a volunteer position with Greene Care Clinic or my termination as a volunteer.

Thank you for your interest in volunteering at the Greene Care Clinic.
Signature
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