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Adult Volunteer Application
PERSONAL INFORMATION
Name
First M.I. Last
Address
Number and Street
City
State
Zip
Phone
Primary (000-000-0000)
Secondary (000-000-0000)
Email Address
Birthday
month/day
EMERGENCY CONTACT
First and Last Name
Phone (xxx-xxx-xxxx)
WORK EXPERIENCE
Current Employer
Current Position
Years of Service
Previous Employer
Previous Position
Years of Service
EDUCATION
Please select highest level of eduation:
High School
Technical/Community College
College or University
Degree or Certificated Received
Are you currently a student?
Please Select
yes
no
If yes, list name of the school(s) you're attending:
Please list areas you are interested in volunteering:
Program Preference
Regions Hospital Volunteer
HealthPartners Specialty Clinics
HealthPartners Administrative Office
HealthPartners Hospice of the Lakes
Bereavement
HealthPartners Clinics
AVAILABILITY
Please indicate days and times available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How many hours do you want to volunteer each week?
How did you learn about our volunteer program?
Tell us why you want to be a volunteer:
REFERENCES
Please enclose a letter of reference or complete the information below.
List the name, address, zip code, and phone number of two references (personal or employment related - if using a relative, please also list a person who is not a relative).
Have you ever been convicted of a misdmeanor or a felony in the past seven years?
Please Select
no
yes
If yes, please explain:
I affirm that the information I have provided in this application form is true and correct to the best of my knowledge. I understand that misrepresentation, omission or falsification of facts in connection with this information may be sufficient cause for cancellation of consideration for volunteer service or termination whenever discovered.
Please Select
yes
no
I understand that as a condition of participation in this program, that I may be required to provide the following: A completed State of Minnesota Criminal Background Study form or Criminal Bureau of Apprehension form, a Mantoux test, reference checks, Failure to cooperate or unsatisfactory results may result in withdrawal of an offer to participate in this volunteer program. As a condition of participation in this volunteer program, I hereby authorize HealthPartners/Regions Hospital volunteer Services to conduct an inquiry into any service-related information contained in this application.
Please Select
yes
no
Volunteers
Volunteer Services
Frequently Asked Questions
Regions Hospital Volunteer Opportunities
HealthPartners Clinical Volunteer Opportunities
