Volunteer Application Web

Adult Volunteer Application
18 years of age or older
Personal Information
Name prefix
First Name
MI
Last Name
Physical Address only; no P.O. Box
City
State
Zip Code
Home Phone
Cell Phone
Work phone
Include area code and dashes.
E-mail address
Date of Birth
Gender
Include birth year for background check purposes.
Residential Status
Application Date
Referral Method
Campus Choice
Downtown - 350 7th Street North
North Naples - 11190 Healthpark Boulevard


Emergency Contact Information
Contact name
Relationship
Home Phone
Cell Phone
Work Phone
Include area code and dashes. Example 239-555-5555
Physician Name
Physician phone

Reference Information
Name
Phone
Include area code and dashes.
Name
Phone
Volunteer Service Area Preference

Education
College Degree:
AA/AS
BA/BS
MA/MS
PhD
Other
Major

Work Experience
Occupation/Former Occupation:
Professional Skills
Computer Skills
Languages
Skills

Background Information

Check yes if you have ever been employed by the NCH Healthcare System or any of its affiliates.

Yes
If yes, include date hired and department.

Check yes if other than a mideameanor traffic violation, you have ever been charged with or convicted for a crime.

Yes
If yes, explain and provide the location (county and state).
Check yes if you have been charged with an unresolved criminal charge. (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?)
Yes
If yes, explain and provide the location (county and state).
Check yes if you are currently on probation.
Yes
The NCH Healthcare System conducts criminal record checks on all incoming volunteers. This is done in accordance with the law and in an effort to enhance patient safety. Falsification or failure to disclose complete information will disqualify you from volunteer service. A conviction does not necessarily disqualify you from volunteer service.
All volunteers will be required to pay for their criminal background check. The criminal background check will be conducted by the NCH Healthcare System. Payment is due at time of orientation via check or cash in the amount of $24.00. NCH Healthcare System will provide your uniform and Tuberculosis testing at no cost. More tangible benefits to volunteering will be presented at orientation. If you are indigent and cannot afford to pay the required fee, please report to the Director or Coordinator of Volunteer Services for assistance.

I certify the above information is correct and the background information has been completed.

I agree
Date
Enter your full name as your online signature here.

Thank you! We will be contacting you to schedule an interview.
We look forward to meeting you!