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Genesys volunteer application

Thank you for your interest in volunteering at Genesys! Please complete the following form in its entirety.


Where would you like to volunteer?
 
1. PERSONAL INFORMATION:
First and Last Name:
Street Address:
City:
State:
Postal Code:
E-mail Address:
Telephone #:
Work Telephone #:
Best time to reach you by phone:

2. REASON YOU ARE APPLYING FOR VOLUNTEER WORK:
 
How did you hear about this volunteering opportunity?

3. PLACEMENT PREFERENCE :




  If other, be specific:
 
Specific Volunteer Service Area assignment(s) you are interested in:

4. AVAILABILITY:
Length of time available to volunteer?


  If Other, please specify:
 
How often:



  If Other, please specify:
 
Select the times you would be available to volunteer by clicking the corresponding box.
Monday
Tuesday




Wednesday
Thursday




Friday
Saturday




Sunday


 
In addition to a regular assignment, are you willing to be called for additional "spot" assignments such as coming in for part of a day to help on (check if interested:)




5. VOLUNTEER EXPERIENCE:
 
Please list any current and prior volunteer experience: including clubs, church, school projects...
 
Hobbies / special interests:

6. EDUCATION: (select the highest year completed)

Elementary
High School






College
Post College






 
Please list any degrees, certificates, professional memberships, licenses:
 
If a current student, please list:
School

Program

Advisor Name / Phone

7. EMPLOYMENT HISTORY: Please list previous employment experience. (List most recent employer first.)
 
Dates
Employer

From (mm/yy)

To (mm/yy)

Name:
Address:
Telephone:
Position:
Department:
Supervisor
Title:
Department:
Reason for Leaving
 
Dates
Employer


From (mm/yy)

To (mm/yy)

Name:
Address:
Telephone:
Position:
Department:
Supervisor
Title:
Department:
Reason for Leaving
 
Dates
Employer


From (mm/yy)

To (mm/yy)


Name:
Address:
Telephone:
Position:
Department:
Supervisor
Title:
Department:
Reason for Leaving
 
8.Have you ever been disciplined, suspended or discharged from employment?
If Yes, please explain
 
9. Is there further useful job-related data or other information that you wish to have us know?


GENERAL INFORMATION:
10. Are you under 18 years of age?
if Yes, please list your age and birth date:
 
11. Have you ever volunteered or been employed at a Genesys Health System Organization?
If Yes, please indicate position:
 
12. Have you ever been convicted of a crime?
If Yes, please complete the following:
 
Date
Where
Charge
Disposition
Please Explain

13. PERSONAL REFERENCES: Please list at least two references other than relatives or employees.
Reference 1
Reference 2
Name:
Address:
Telephone:
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.

Your appointment for a personal interview will be scheduled when your completed application is received.






 

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