Volunteer Application

Please Print Clearly!
When complete, return to: JoElla Dales, Volunteer Coordinator

Name: ____________________________________________         Date: ________________________

Home Phone: __________________ Cell: __________________ Business: ______________________

E-mail: _________________________________________________________________

Preferred method of contact:  __ Home   __ Business   __ E-mail   __ Any

 CURRENT or MAILING ADDRESS

 Address ____________________________________________  City / State _________________ Zip ______________

 PERMANET ADDRESS (if different) 

Address _____________________________________________City / State __________________ Zip _____________

EMPLOYMENT INFORMATION

I am: __ Employed   __ Un-employed   __ Retired   __ Student

Employer / School _________________________________________Occupation _________________ 

Employer Address __________________________ __________________________Department / Suite Number _______

City / State ________________________________ Zip ____________ Business Phone ______________________

Professional Employment / Practice History

Date Started              Date Ended                    Position                              Responsibilities

 

EDUCATION

(Check all that apply – please note degrees in progress)

__H.S. diploma: School _______________________________________City / St. _____________________ Yr ________

__ Undergrad degree: School __________________________________City / St. ______________Yr _____ Major _____

__ Grad degree: School _______________________________________City / St. ______________Yr _____ Major _____

Educational Training / Licenses or Certifications (list all applicable degrees & credentials): _________________________________________________________________________________________________

_________________________________________________________________________________________________

** PLEASE ATTACH A PHOTOCOPY OF YOUR CURRENT PROFESSIONAL LICENSES. **

 

___ I am age 18 or older      Birthday: __________________   Gender: ______________

Any languages other than English (including sign language)? ______________________

SERVICE OPPORTUNITIES

What do you want to do? Order your interests by NUMBER (first choice = 1, second choice = 2, ect.). For job descriptions, requirements, & time commitments, see the Volunteer Information Book at our front desk or call the Volunteer Coordinator.

MEDICAL CLINIC                                                    ADMINISTRATIVE
____ Patient Registration (History Taker)                    ____ Clerical / Typist
____ Lab Tech / Phlebotomist                                    ____ Computer Work / Data Entry
____ Pharmacy Technician                                        ____ Chart Filing
____ Registered Pharmacist                                      ____ Other
____ Well Physical Examiner (med students)              
____ Practitioner / Physician                                     SPECIAL PROJECTS
____ Resident                                                          ____ Remote Area Medical
____ Certified Nursing Assistant                                ____ ETSU Health Fair
____ Medical Clerical Support & Projects                  
____ RN / LPN                                                        COMMUNITY EDUCATION
____ Nutritionist / Dietician / Diet Tech                      ____ Health Education Outreach
____ Nurse Practitioner
____ Dental Student
____ Student Intern
____ Therapist
____ Psychiatrist
____ Intake Worker

Have you volunteered at St. Mary’s Health Wagon before? ________________________
How did you hear about our needs at St. Mary’s Health Wagon? ____________________
Is there anything else you would like us to know about you (i.e., career goals, special needs, etc.)?_________________________________________________________________________________________________

_________________________________________________________________________________________________

How often would you like to volunteer?

__ one time / specific project __ 1-2 times per month __ 1x / week __ 2x / week

__ more than 2x / week

How long of a commitment can you make as a volunteer?  
__ 3 months        __ 6 months       __ 9 months         __ more than 1 year

PLEASE LIST THE TIMES YOU ARE AVAILABLE TO VOLUNTEER BELOW

  Monday    Tuesday    Wednesday    Thursday    Friday   Saturday   Sunday

Morning’s______________________________________________________________

Afternoon’s____________________________________________________________

TWO REFERENCES MUST BE PROVIDED BEFORE YOU BEGIN YOUR SERVICE

*Both Volunteer Professional Reference Check Forms must be attached with your Application.