| First Name: |
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| Last Name: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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Email:
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Phone:
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| Cell Phone: |
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| Birth Day: |
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Emergency Contact
First Name: |
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| Emergency Contact Last Name: |
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| Emergency Contact Relationship: |
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Emergency Contact Phone:
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| Emergency Contact Cell Phone: |
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| Currently Employed: |
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| If yes, please list current employer: |
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| Have you ever worked as a volunteer before?: |
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| If yes, where: |
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| Year(s): |
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| What were your responsibilities/service areas? |
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| Which service area, what year and reason for leaving? |
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| Are there any restrictions or limitations on your activity? If so, please explain. |
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| Have you ever been convicted, plead guilty, plead no contender, or forfeited bond to a violation of any federal, state, county or municipal law, regulation or ordinance other than motor traffic violations? |
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| Please summarize skills, abilities or talents you have to offer as a volunteer (typing, computer skills, languages, etc.): |
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| Check days preferred: |
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| Time of day preference: |
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| AGH Functional interest(s): |
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| Other areas: |
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| I understand that Atlantic General Hospital (AGH) reserves the right to accept or reject my application at its sole discretion and that the above statements made in this application are true. I understand that my service will be in accordance with the general personnel policies and guidelines of AGH and that AGH may, at their expense conduct a background check. I further understand that I may quit at any time with or without cause and should the Volunteer Coordinator feel that the interests of the AGH are best served by relieving me of my assignment or transferring me to another area, I agree to accept the decision as final. Believing that AGH has a real need of my services as a volunteer who serves without pay, I will uphold the Mission and Values of Atlantic General Hospital. |
| Signature: |
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