Volunteer - Hospital Application

	Personal Information
* Name
* Street Address
* City
* State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * Zip Code
* Phone Number
* Email Address
* Birthdate	month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 year 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Are you a   U.S. citizen?	yes  no
	Occupation Information
Present Occupation
Employer
Phone Number
Education and Training
	Volunteering History
Volunteer Experience
Have you ever   worked or volunteered   in a healthcare setting?	yes  no
If yes, please describe
	Contact for Medical Clearance
* Your Physician's Name
* Street Address
City
State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code
	Personal History
Have you ever been   convicted of a crime?	yes  no
If yes, please describe
Have you ever had   a discharge from   any military service?	yes  no
If yes, please describe
	Personal Interests
Hobbies,   special interests,   organizations   (church, civic, etc.)
	Personal Reference #1 (other than family)
* Name
* Street Address
* City
* State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * Zip Code
* Phone Number
	Personal Reference #2 (other than family)
* Name
* Street Address
* City
* State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * Zip Code
* Phone Number
	Availability to Volunteer
Days available   (check all that apply)	Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Times available	morning afternoon evening weekly biweekly monthly
	Desire to Volunteer
Why do you wish   to volunteer   at St. Francis?
Do you have a   preference as to where   you volunteer?	yes  no
If yes, where
	Emergency Notification
	Notify in case of emergency:
* Name
* Relationship to You
* Street Address
* City
* State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * Zip Code
* Home Phone
* Business Phone
* Enter Code from Image

I certify that answers given here are true and complete to the best of my knowledge.

I hereby give St. Francis permission to contact the listed references, physician, and to conduct a drug screening or criminal check if appropriate.

A health assessment and safety training are required by the hospital. I understand that volunteer placement is contingent upon completing all initial and future health requirements and training as required by Bon Secours St. Francis Health System.

* I agree with the above statements.