Volunteer Application

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

Social Security #: (Optional)

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
	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY	SATURDAY	SUNDAY
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