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We are proud to provide equal volunteer opportunities to all qualified applicants and volunteers irrespective of race, color, national origin, sex, gender identity or expression, religion, age, disability or veteran status.
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:
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
GU
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
Please specify:
Do you have any Allergies?
Yes
No
Please specify:
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
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
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RI
SC
SD
TN
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PR
GU
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Degree ⁄ Diploma
College / University
Name
City
State
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
GU
From
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Degree ⁄ Diploma
Other
Name
City
State
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
GU
From
MM
01
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YYYY
2012
2011
2010
2009
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To
MM
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YYYY
2012
2011
2010
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1931
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1929
1928
1927
1926
1925
1924
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1922
1921
1920
Degree ⁄ Diploma
Volunteer History:
Organization Name:
Address:
Suite:
City:
State:
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
GU
ZIP:
Phone:
Reason for leaving:
Organization Name:
Address:
Suite:
City:
State:
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
GU
ZIP:
Phone:
Reason for leaving:
Organization Name:
Address:
Suite:
City:
State:
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
GU
ZIP:
Phone:
Reason for leaving:
Military Service:
Served From
MM
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1941
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
To
MM
01
02
03
04
05
06
07
08
09
10
11
12
YYYY
2012
2011
2010
2009
2008
2007
2006
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2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
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1975
1974
1973
1972
1971
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
If yes, when and what charge or charges?
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
If yes, please specify:
Windows
MS Word
MS Excel
MS PowerPoint
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
select
14
15
16
17
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.
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