Volunteer Application

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Please fill in this form as completely as possible. Items marked with a * are required.

I am a*: Adult College student Stipend Intern Other

^ Please select one

Mr. Mrs. Miss Ms.

Nickname:

Last Name*: First Name*: Middle Initial:

^ Please enter your last name
^ Please enter your first name

Date of birth*: Month Day Year (Optional)

^ Please enter your month of birth
^ Please enter your day of birth

I am:*

^ Please select your current employment status

Address

Street*:

^ Please enter your street address

City*: State*: Zip*:

^ Please enter your city
^ Please enter your state
^ Please enter your zip code

Home phone:

Cell phone:

E-mail:

Home Address (if college student)

Street*:

City*: State*: Zip*:

Home phone:

(Please check one*) Employed by Retired from
Company Name: Position: Phone:

^ Please check one

Why do you want to volunteer at Children's*:

^ Please tell us why you want to volunteer at Children's

Past volunteer experience:

Experience working with children*:

^ Please explain any experience working with children

List Interests/Skills/Hobbies*:

^ Please List Interests/Skills/Hobbies

Education

High school: Year of Graduation: College: Year of Graduation: Degree:

PLEASE CHECK THE TIMES YOU ARE AVAILABLE TO VOLUNTEER
MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYSUNDAY
Mornings
Afternoon
Evenings

How long do you plan to volunteer?


References

1. Name*: Phone:
Address:
City: State: Zip:

^ Please supply two references

2. Name*: Phone:
Address:
City: State: Zip:

^ Please supply two references


Emergency information

Person to notify*: Relationship:
Home phone: Work phone:
Cell phone:

^ Please supply emergency contact information
Physician*: Phone:
^ Please supply your physician's contact information

Have you ever been convicted of any offense (other than a minor traffic violation)*?
Yes No

^ Please tell us - Have you ever been convicted of any offense (other than a minor traffic violation)?

If yes, please explain:

(Conviction of some offenses result in ineligibility to volunteer in a pediatric environment per Senate Bill 187 effective 03/01.)

All volunteers are subject to fingerprinting and background checks.


By submitting this form, I understand that I am expected to volunteer a minimum of 100 hours or for a one-year period. I will uphold The Children's Medical Center of Dayton's rules of conduct, policies and procedures. I understand that for the health and safety of our patients and staff, Dayton Children's employees and volunteers are prohibited from smoking on hospital grounds or during work shifts.

Revised 02/01, 02/02, 08/02, 12/03, 08/07, 3/10

 

Upcoming Events

Car Seat Safety Check at Evenflo in Miamisburg

Join the Dayton Children's Air Force Marathon Team and run for kids who can't September 20, 2014.

Car Seat Safety Check

The Fuel the Miracles Car & Bike Show will take place September 27 at the Moraine Walmart.

Learn about healthy lifestyles including exercise and nutrition!

Car Seat Safety Check at Xenia Township Fire Station 51 on Brush Row Road

View full event calendarView full event calendar

Ways to Help

Learn how you can make a difference

Accreditations

The Children's Medical Center of Dayton Dayton Children's
The Right Care for the Right Reasons

One Children's Plaza - Dayton, Ohio - 45404-1815
937-641-3000
www.childrensdayton.org