Volunteer Application Form

AVAILABILITY

Please indicate the days/times that you are available for the respective days that you chose.
Availability *

Monday Tuesday Wednesday Thursday Friday Saturday
Monday *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Tuesday *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Wednesday *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Thursday *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Friday *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Saturday *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option

References

Submit information for two references that we may contact about your personal qualities, characteristics, and capabilities.
Name *

First Name Last Name
Job Title *
Company *
Email *
example@example.com
Phone Number *

Area Code Phone Number
Relationship *
How long have you known this person: *
Name *

First Name Last Name
Job Title *
Company *
Email *
example@example.com
Phone Number *

Area Code Phone Number
Relationship *
How long have you known this person: *

I understand that Upstate AHEC will interview me about my background, motivation, values, expectations, and other personal qualities to determine whether I would be an appropriate volunteer. I also understand that Upstate will review references and investigate any and all facts concerning my qualifications for becoming a volunteer. *
Initial
I authorize Upstate AHEC to conduct a background check, which may include but isn't limited to both a state and federal inquiry and the Sexual Offender Registry. I understand that I will not be able to actively serve as volunteer until my background check clears and all information included in my application has been verified by an employee of Upstate AHEC. *
Initial
I understand that I am not obligated to perform the volunteer services applied for, however, I agree to inform Upstate AHEC when I am no longer available and/or interested in providing volunteer services. I understand that Upstate AHEC is not obligated to utilize me as a volunteer. *
Initial
I agree to keep information discussed with me about students in the program confidential. I will not discuss this information with anyone other than the Health Careers Program Coordinator or the Executive Director at Upstate AHEC. I understand that if a student that I am working with informs me of incidents of child abuse or molest, past or present, or threat of harm to oneself or others, that I must report this information to Upstate AHEC and to the proper authorities. *
Initial
By submitting this application, I agree that I am hereby applying for membership as a volunteer at Upstate Area Health Education Center (AHEC). I certify that all information provided on this application is complete, true, and accurate. I acknowledge that intentional omission or falsification of information from this application will result in non-acceptance or immediate dismissal from Upstate AHEC’s volunteer program.

I understand that submitting this application does not guarantee my acceptance into Upstate AHEC's volunteer program and that if selected, Upstate AHEC reserves the right to terminate this relationship at any time without explanation.
Signature *
Please type your Full Name.
Date *

Month Day Year
Date
Should be Empty:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Community Partner & Volunteer Application