Adult Volunteer Application

Application Date*

MonthDayYear

Volunteer Location (please check at least one)*

Cherry HillStratfordWashington Township

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth*

Date

Phone Number*

Area CodePhone Number

E-mail*

Employment Status*

EmployedRetiredUnemployed

Person to notify in case of an emergency:

Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Work Experience (please provide company names, dates of employment and position)*

Do you prefer patient contact?*

YesNo

Do you prefer a special assignment?*

YesNo

If yes, where?

Skills you would like utilized in your volunteer assignment

Availability (please fill in all available times)*

	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
9am - 12:30pm
12:30pm - 4pm
4pm - 7:30pm

What do you hope to gain from your volunteer experience at Jefferson?*

Personal References (2)

Please complete all information, and family members are not allowed.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Statement of Agreement

I understand that I must be punctual and regular in attendance, helpful in my assignment and careful to honor the confidential nature of what I observe and all other rules and regulations of the Volunteer Services Department. I understand that my service as a volunteer is conditional, based on need and satisfactory service, and may be canceled at any time.

I understand that due to the extensive onboarding process for both the volunteer and Kennedy Health, we require a 6 month, 100 hour commitment before supplying service documentation or supporting application for a paid position at Kennedy.

I certify that the above information is true and correct to the best of my knowledge. I understand any false statement on this application may be considered cause for rejection of this application or for dismissal if such statement is discovered subsequent to an assignment. I agree that if offered an assignment, I will consent to the proper health screenings. I understand continued volunteer service is contingent upon completion of the screening and results.

Date*

MonthDayYear

Applicant's Digital Signature*

Type Captcha Word to Verify Submission*