| Name |
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| Address |
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| Phone |
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| email |
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| Birthday (day/month) |
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| Emergency Contact - name and phone |
| |
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| Work Experience - Current Employer |
| Name |
|
| Current Position |
|
| How long |
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| Work Experience - Previous Employer |
| Name |
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| Previous Position |
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| How long |
|
| Education - Are you a student? |
| |
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| 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 |
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| Thursday |
|
| Friday |
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| Saturday |
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| Sunday |
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| Total hours available per week |
|
| How did you learn about our volunteer program? |
| |
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| 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). |
| |
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| Have you ever been convicted of a misdmeanor or a felony in the past seven years? |
| |
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| If yes please explain |
| |
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| 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. |
| |
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| 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. |
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