Thank you for your interest in volunteering at Ascension Genesys. You must have a valid e-mail address in order to be considered for a volunteer role. Please complete the information below. We look forward to receiving your application.
Genesys Volunteer Application
Personal Information
First Name
Last Name
Home Address
Zip Code
City
State
Home Phone (555-555-5555)
Cell Phone
E-mail Address
Best time to reach you by phone:
Please check if you are a year-round resident.
If not, what months are you available?
January
February
March
April
May
June
July
August
September
October
November
December
Please check to confirm that you are age 18 or older.
(You must be at least 18 years old and graduated from high school in order to volunteer.)
Gender
Female
Male
Not disclosed
Emergency Contact Information
Contact name
Phone (must be different from your phone number)
Relationship
Education
Some High School
High School Graduate
Some College
College Graduate
Post College
Grade Level Completed
Major/Degree
Other training, certificates, professional memberships, licenses:
If you are a current student, please list:
School
Program
Advisor Name / Phone
Work Experience
Please list most recent first:
Employer
Job Title
Job Duties
Length of Service
Less than 1 year
1 to 5 years
More than 5 years
Reason for leaving
Employer
Job Title
Job Duties
Length of Service
Less than 5 years
1 to 5 years
More than 5 years
Reason for leaving
Current Employment Status
Currently Employed
Retired
Student
Looking for employment
Homemaker
Other
Have you previously been employed in the Genesys Health System?
Yes
No
If yes, please explain:
Has a family member previously been employed in the Genesys Health System?
Yes
No
If yes, please explain:
Have you ever been disciplined, suspended or discharged from employment?
Yes
No
If yes, please explain:
Is there further useful job-related data or information that you wish to have us know?
Volunteer Experience
Organization
Role/Duties
Length of Service
Less than 1 year
1-5 years
More than 5 years
Organization
Role/Duties
Length of Service
Less than 1 year
1-5 years
More than 5 years
Organization
Role/Duties
Length of Service
Less than 1 year
1-5 years
More than 5 years
Organization
Role/Duties
Length of Service
Less than 1 year
1-5 years
More than 5 years
Please note that placements may have limited availability.
Placement Preference:
Patient Area
Public Area
Fundraising
Clerical
Greenhouse
Retail (Gift Shop/Flower Cart)
Other
If other, please specify:
Specific Volunteer Service Areas you are interested in:
Activity Cart
Courtesy Van Driver
Emergency Department
Eucharistic Minister
Flower Cart
Fundraising
Gift Shop
Greenhouse
Greeter/Escort
Lab Transport
Mealtime companion
Nursery
Office/Clerical
Packet Assembly
Patient Visitor
Pet Therapy
If other, please specify:
If Pet Therapy is specified please provide dog's name, breed, and certification:
Volunteer Work Objectives:
Develop skills
Have fun and relax
Help the community
Learn new skills
Make worthwhile use of freetime
Meet and work with people
Personal enrichment
Use skills
Other - please specify:
If other, please specify:
Volunteer Experience Activity Level:
Very Active (capable of walking distances and pushing wheelchairs)
Moderately Active (some walking)
Limited Activity (requires mostly sitting)
Hobbies
Skills:
Accounting/Finance
Administration/Office
Adult Literacy
Artist
Audio/Visual
Child Care
Clerical
Computer - Data entry
Computer - IT general
Construction - Carpentry
Construction - Electrical
Construction - General
Construction - Painting
Construction - Plumbing
Custodial
Customer Service
Electronics
Event Planning
Food Services - Delivery
Food Services - Preparation
Fundraising
Gardening
Grant Writing
Graphic Design
Language/Translator
Law Enforcement
Legal
Library
Management
Management-Facilities
Management-Project
Management-Retail
Marketing/Communications
Medical - CPR
Medical - Doctor/Physician
Medical - First Aid
Medical - General
Medical - Nursing
Medical - Pharmacist
Medical Assistant
Musician
Patient Interfacing
Photography
Political/Government
Presentation
Process Improvement / Lean
Public Relations
Public Speaking
Reading
Sales/Cashier
Santa Claus
Sports - Coaching
Sports - Official
Teacher
Teacher - Hearing Impaired
Teacher - Special Ed
Telephone
Transportation - Driver (bus/van)
Transportation - Driver (car)
Transportation - Emergency
Transportation - Moving
Transportation - Parking
Veteran
Video Production
Writing/Reporting
Please check all skills that apply:
Other skills, please specify:
How did you hear about this volunteering opportunity?
Have you ever been convicted of a felony or a misdemeanor?
Yes
No
If yes, please complete the following:
Date
Location
Charge
Disposition
Please explain:
Personal References
Reference 1
Reference 2
Name:
Address:
Telephone:
(555-555-5555)
City, State Zip:
Relationship:
Years Known:
Acknowledgement: I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I understand a misrepresentation of facts constitutes cause of separation. If placed I will volunteer on a regular basis, be dependable, and honor all Genesys Health System and volunteer policies and guidelines. I hereby authorize present and former employers, associates, schools, credit organizations, law enforcement agencies, military organizations, and/or other persons to provide Genesys Health System with any information which may aid in determining my suitability for volunteering. Additionally, I release those individuals and/or organizations contacted from all liability whatsoever for issuing the requested information, and hereby waive my right to receive written notice of any such information provided. I also hereby release Genesys Health System, its affiliates and employees from any and all liability and damages for requesting, releasing, and using information concerning me, my work and performance record. It is clearly understood that there is no employer/employee relationship and that as a service volunteer I am not entitled to compensation or fringe benefits of any kind for voluntary services.
By submitting this application on-line, I agree to the above written statement.