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)*

NoYes
Date of Offense*

MonthDayYear
Date
Nature of Offense*
Disposition*
Do you have a current driver's license?*

YesNo
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*

Clear
Should be Empty: