Thank you for your interest in volunteering at Genesys Regional Medical Center. 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?
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
Emergency Contact Information
Contact name
Phone (must be different from your phone number)
Relationship

Education
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
Reason for leaving
Employer
Job Title
Job Duties
Length of Service
Reason for leaving
Current Employment Status
Have you previously been employed in the Genesys Health System?
If yes, please explain:
Has a family member previously been employed in the Genesys Health System?
If yes, please explain:
Have you ever been disciplined, suspended or discharged from employment?
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
Organization
Role/Duties
Length of Service
Organization
Role/Duties
Length of Service
Organization
Role/Duties
Length of Service
Please note that placements may have limited availability.
Placement Preference:
If other, please specify:
Specific Volunteer Service Areas you are interested in:
If other, please specify:
If Pet Therapy is specified please provide dog's name, breed, and certification:
Volunteer Work Objectives:
If other, please specify:
Volunteer Experience Activity Level:
Hobbies
Skills:
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?
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.