Volunteer Form

Name

Title

Mr.Mrs.Ms.Dr.Other:

* Last name:

* First name:

Middle name:

Preferred Nickname:

Gender:

FemaleMale

Home Address

* Street Address:
Apt Number:
* City:
* State:
* Zip code:
How long have you lived at this address?
Is anyone else at this address already a volunteer here?	NoYes
If yes, what is their name?
Are you currently employed by CMC?	NoYes
Have you volunteered for this organization before?	NoYes
If yes, what year?

Contact Information

Personal Information

Last 4 Digits of Social Security Number
Date of Birth
Spouse's Name (If Married)

Education (Check all that apply)

Employment Information

I am:
Employed Full TimeEmployed Part TimeUnemployedRetiredStudent
Current Employer's Name (or School):
Current Occupation:

Work Schedule

What days do you work?

What hours do you work?

Previous Employer or work experience:

Past or Present volunteer experience:

Have you ever been convicted of a Felony?

NoYes

I want to be a volunteer because:

Reasons you would like to become a CMC volunteer:

How did you find out about our volunteer program?
Called CMC Was a patient Ask A Nurse Newspaper Poster/Flyer Brochure Was referred by someone.
Name:
Relation: VolunteerEmployeeFriend
What types of volunteer activities would you like to be involved in?
Hobbies/Skills/Interests:
General area in which I would prefer to serve:
CMC Prime Time Parish Nurse Great Day Community Health Services Our Place NH Center for Rehab & Sports Medicine

Availability

Extra information

Are you able to make a minimum commitment of six consecutive months of volunteer service?	YesNo
Date you can begin volunteering:
Please note: to be considered a "currently active" volunteer you must continue to contribute a minimum of 50 hours of volunteer service per year.
Do you have any medical conditions that would affect your ability to perform your volunteer duties, or that the volunteer office should be aware of? YesNo
If yes, please explain:

Please provide any additional information that might help us place you in a volunteer assignment, or that you feel would be pertinent to your application.

Personal References

Please list two people, who have known you for more than one year, who would be willing to serve as personal references.
1.	* Name * Relationship	Address (street, city, state, and zip)	* Phone #
2.	Name Relationship	Address (street, city, state, and zip)	Phone #
I certify that the statements made in this volunteer application are true and complete, and have been given voluntarily. I understand that any misrepresentation or omission of fact shall be considered sufficient cause for termination of my volunteer service. I agree that Catholic Medical Center and any of the references provided on this application, may exchange information regarding my qualifications without incurring any liability whatsoever for supplying such information. I understand that I will not be paid for my services as a volunteer. I agree to abide by all organization and volunteer policies. I understand that CMC is not obligated to provide volunteer placement, nor am I obligated to accept the volunteer assignment offered.
Please note: Volunteer placement is subject to:
Satisfactory reference reports. Satisfactory medical history review and required testing. Personal interview with the Director of Volunteer Resources, and/or department staff as required. Willingness to abide by all hospital requirements and regulations.

Catholic Medical Center | 100 McGregor Street | Manchester, NH 03102

Phone: 800.437.9666 or in-state at 603.668.3545