Volunteering at a Care New England Organization

Select your program of Interest

	Adult Volunteer
	Capstone/Senior Project
	Career/Technical School Internship
	Corporate Partners Programs
	Community Service
	EMT/EMTP Internship
	Internship
	Job Shadowing

	Music Gives Back
	Nail Program
	PA Internship
	PA Job Shadow
	Pet Therapy Program
	Reiki Program {1 year min.}
	Rehab Intership
	Teen Volunteer
	Other

Mr.

Miss

Ms.

Mrs.

Name

Last

First

Middle

Nickname

Address:

Address 1:

Apt/Suite:

City:

State:

ZIP:

Date of Birth

Drivers License #

License Plate #

Contact Information:

Home Phone #:

Cell Phone:

Email:

Work:

Organization/Company:

Phone:

Health Information

Primary Care Physician

Office Phone

Fax

Are you presently taking any medications?

Yes

No

Do you have any Allergies?

Yes

No

Please supply Employee Health Office with any other pertinent health information that you think may be necessary for us to have on file.

*If you are under the age of 18 — Please bring your most recent vaccination record.

Emergency Contact

1)

Name

Relationship to You

Phone #

2)

Name

Relationship to You

Phone #

Education

Please include the following — Name, City/State, Dates Attended, Diploma/Degree

HighSchool

Name

City

State

From

To

Degree ⁄ Diploma

College / University

Name

City

State

From

To

Degree ⁄ Diploma

Other

Name

City

State

From

To

Degree ⁄ Diploma

Volunteer History:

Organization Name:

Address:

Suite:

City:

State:

ZIP:

Phone:

Reason for leaving:

Organization Name:

Address:

Suite:

City:

State:

ZIP:

Phone:

Reason for leaving:

Organization Name:

Address:

Suite:

City:

State:

ZIP:

Phone:

Reason for leaving:

Military Service:

Served From

To

Licenses:

Have you ever been sentenced or convicted for any violation of the law?

Yes

No

A "yes" will not be an absolute bar to a volunteer program

Do you speak another language fluently other than English? If so, which language(s)?

Volunteer Services Preferred:

Direct Patient/Visitor Contact

Non-Patient

Clerical

Program Area of Interest:

Why are you interested in Kent Hospital?

How did you learn about our programs here at Kent Hospital?

Computer Skills

Yes

No

Other

Please indicate the days and times you are available:

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

---OFFICAL USE ONLY---

*Please note that adult/teen volunteers are required a minimum of a 4 month commitment

References:

1) *


Name	Relationship/Occupation


Address	Phone No.	Years Known

2) *


Name	Relationship/Occupation


Address	Phone No.	Years Known

Miscelaneous

Have you ever worked or volunteered at any CNE Organization?

If so, please list dates:

List the name of relatives/friends currently employed or volunteering at Kent Hospital.

Special Hobbies/Interests:

Community/Organization Affiliations:

Volunteer Agreement:

I hereby certify that the answers given by me to the foregoing questions and the statements made by me are full and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, or any supplements thereto, is cause for rejection of my application or discharge at any time during my volunteer or program commitment. I understand that as a condition, I will be required to complete the organization's pre-volunteer physical examination and background checks. I understand that any offer of volunteerism is contingent on my producing appropriate documentation verifying my identity. I agree to abide by and observe all rules and regulations of Kent Hospital. I voluntarily authorize my former employers, schools, and persons named herein to give information regarding me, whether or not such information is part of their records. I hereby release said organizations or persons from any liability or damages whatsoever for issuing this information.

Junior Volunteer Parent/Guardian Consent Form:

I authorize my daughter/son age to participate in the Teen Volunteer Program at Kent Hospital and to engage in such volunteer activities as may be assigned by the Director of Volunteer Services or a designated representative. I give my permission to the hospital for the enrollment of this minor. I release Kent Hospital and its agents from any claim or liability for any present or future injury or illness resulting to said minor, not occasioned by any fault or neglect on the part of the hospital, while participating in such volunteer activities.

Click to attach additional documention.