Volunteer Application

At which Community Health Network location would you be interested in volunteering?

Applicant Contact Information

* Legal First Name

Middle Name

* Legal Last Name

* Date of Birth

Applicant Race

Gender

* Home Address

Home Address Continued

* City

State (as combo)

* Zip Code

* E-mail Address

* Home Phone Number

* Mobile Phone Number

Business Phone Number

Emergency Contact Information

* Emergency Contact Full Name

* Relationship to Applicant

* Home Phone Number

* Mobile Phone Number

Business Phone Number

Employment Information

What is the name of your current employer?

Have you ever been employed by any Community Health Network Hospital or Affiliate?

If yes, please list the location and position

Volunteer Experience

Please list any current volunteer experiences

Please list any past volunteer experiences

Applicant History

Have you ever been discharged from any position?

If yes, please explain

Have you ever been convicted of a crime (felony and/or misdeameanor)? You must include driving violations involving the use of illegal substances or cases sealed or expunged by a court.

If yes, please list the charge/offense, date, arresting agency/location, and court disposition

Do you have any criminal charges pending?

If yes, please give the date and nature of all pending charges

Have you lived in Indiana for 2 years?

* Please explain the reason for your interest in volunteering

* How did you hear about the Volunteer Services program with Community Health Network?

Are you willing to be an active volunteer for at least 6 months?

Although positions are assigned based on shift availability, please list your preferred days and times

* Please list your skills and interests

Are you at least 16 years of age?

Education History

Please indicate the last grade of high school completed

Please list the name of your high school

Please indicate your high school grade point average

Please indicate the last grade of college completed

Please list the name of your college

Please indicate your college grade point average

I certify the statements on this application are true and correct to my knowledge. I certify that I am not currently debarred, excluded, or otherwise ineligible for participation in federal health care programs. I understand that falsification, misrepresentation, or omission of information requested on this application will result in immediate dismissal, regardless of the date of discovery. I understand the Network will make a thorough investigation, including a criminal history investigation, of my entire personal history and may verify all data given in my application. I authorize such investigation and the giving and receiving of any information required by the Network. I release from liability any person giving or receiving such information now or in the future. I understand falsification of data given or derogatory information discovered as a result of this investigation may prevent my being accepted as a volunteer, or, if accepted, may subject me to immediate dismissal. I understand that my volunteering depends upon satisfactory references and successful completion of a physical examination and meeting all Network requirements. I also acknowledge and understand this application is not a contract of employment, and that if I am accepted as a volunteer, I will be an at-will volunteer and may voluntarily leave my volunteer position upon proper notice. I understand that my volunteer position may be terminated at any time for any reason. I acknowledge that no written or oral statements or promises have been made to or relied upon by me regarding the length of my volunteer position or the reasons for which my volunteer position can be terminated. If accepted as a volunteer, I agree to abide by and conform to all rules, policies, and procedures of Community Health Network.

****For applicants under the age of 18, parent or guardian signature is required under applicant signature in below box to signify permission for applicant to become a member of the Community Health Network volunteer program.

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Applicant Signature / Parent/Guardian Signature (if applicant is under the age of 18)

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VSys Volunteer Application