volunteer application

Before completing this application please note the following:

All volunteers are expected to volunteer a minimum of 100 hours or for a one-year period.
All volunteers are required to have an annual flu vaccine in order to work at Dayton Children’s. It will be provided to you free of charge. You will not be considered for a volunteer position if you are unable to complete this requirement each year.
High school students must follow our application process for volunteens and should not use this form. Please visit our Volunteen page for more information.
Once we receive your application it can take up to two weeks for you to hear from us and up to eight weeks before you may be able to start your volunteering if your application is accepted.

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

I am a:

Gender

Nickname:

Last Name:

First Name:

Middle Initial:

Date of birth:

I am:

Address

address

Street:

City:

State:

Zip:

Home phone:

Cell phone:

E-mail:

Home Address (if college student)

home address (if college student)

Street:

City:

State:

Zip:

Home phone:

(Please check one)

Company Name:

Position:

Phone:

Why do you want to volunteer at Children's:

Past volunteer experience:

Experience working with children:

List interests/skills/hobbies:

Tell of a time when you had to take precautions to ensure safety for yourself or others.

Describe one situation in which you’ve worked hard to meet or satisfy a customer’s needs.

At times we aren’t always satisfied with our performance. Tell about the most memorable time that you weren’t pleased with your performance and what did you do about it.

Tell about a time you worked with others to develop new and creative ideas to solve problems. What was your role in the situation?

Give an example of a time when your team/group accomplished it's goals. What was your role?

Tell of a time when you noticed a process or task was being done incorrectly. What did you do?

Explain a time when you received poor customer service from any type of business. How did you feel?

Education

education

High school:

Year of Graduation:

College:

Year of Graduation:

Degree:

PLEASE CHECK THE TIMES YOU ARE AVAILABLE TO VOLUNTEER

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How long do you plan to volunteer?

References

references

Name:

Phone:

Address:

City:

State:

Zip:

Name:

Phone:

Address:

City:

State:

Zip:

Emergency information

emergency information

Contact #1:

Person to notify:

Relationship:

Home phone:

Work phone:

Cell phone:

Contact #2:

Person to notify:

Relationship:

Home phone:

Work phone:

Cell phone:

Physician:

Phone:

Have you ever been convicted of any offense (other than a minor traffic violation)?

If yes, please explain:

Markup 1

(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.

Markup 2

By submitting this form, I understand that I am expected to volunteer a minimum of 100 hours or for a one-year period and that I must receive a mandatory annual flu vaccine. I will uphold Dayton Children’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.

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