Adult Volunteer Application

Name
Address
Phone
email
Birthday (day/month)
Emergency Contact - name and phone
Work Experience - Current Employer
Name
Current Position
How long
Work Experience - Previous Employer
Name
Previous Position
How long
Education - Are you a student?
	yes no
Where
	High School  Technical/Community College  College or University  Degree or Certificated Received
Program Preference
	Regions Hospital Volunteer  HealthPartners Specialty Clinics  HealthPartners Administrative Office  HealthPartners Hospice of the Lakes  Bereavement  HealthPartners Clinics
List areas of interest
Indicate days and times when available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total hours available per 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?
	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.
	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.
	yes no

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