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

Where would you like to volunteer? Please select one Center for Gerontology (Flint) Genesys Convalescent Center (Grand Blanc) Genesys Hospice (Goodrich) Health Park (Grand Blanc)

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:

Personal Enrichment Gain/practice skills; what skills? Other reason; please explain:

How did you hear about this volunteering opportunity?

3. PLACEMENT PREFERENCE

Patient Area Public Area Fundraising Clerical Other  If other, be specific:

Specific Volunteer Service Area assignment(s) you are interested in:

4. AVAILABILITY:

Length of time available to volunteer?

One Year More than One Year Other  If Other, please specify:

How often:

Weekly Twice a Month Monthly Other  If Other, please specify:

Select the times you would be available to volunteer by clicking the corresponding box.

Monday Tuesday Morning Afternoon Evening Morning Afternoon Evening Wednesday Thursday Morning Afternoon Evening Morning Afternoon Evening Friday Saturday Morning Afternoon Evening Morning Afternoon Evening Sunday Morning Afternoon Evening

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:)

Event Host/Hostess Medical Center Tour Host/Hostess Bulk Mailing Preparation Xeroxing

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 1 5 2 6 3 7 4 8 9 10 11 12 College Post College 1 2 3 4 1 2 3 4

Please list any degrees, certificates, professional memberships, liscenses:

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 Emplolyer 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? Yes No

If Yes, please explain

9. Is there further useful job-related data or other information that you wish to have us know?

10. EMERGENCY CONTACT:

Name:

Street Address:

Telephone #: Work Telephone #:

Relationship:

GENERAL INFORMATION:

11. Are you under 18 years of age? Yes No

if Yes, please list your age and birth date:

12. Have you ever volunteered or been employed at a Genesys Health System Organization? Yes No

If Yes, please indicate position:

13. Have you ever been convicted of a crime? Yes No

If Yes, please complete the following:

Date Where Charge Disposition

Please Explain

14.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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