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Basic Information

Salutation:

Full Name:

Home Phone:

Cell Phone:

Email:

Address:

Address:

City:

State:
Zip:



Emergency Contact
Full Name:

Relationship to You:

Phone:

Email:

Address:

Address:

City:

State:
Zip:



About Volunteering
What do you hope to gain from your volunteer experience?

What is your current occupation?

Please describe any prior or present volunteer or community activities:

Please list any skills, hobbies or interests which will help us place you appropriately:

Are you a member of the CDH Auxiliary?

Were you ever employed by CDHCC?

Are you a member of RSVP?

Have you ever volunteered at CDH before?




Your Availability
Please note best days and times.
8am - Noon

Noon - 4pm

4pm - 8pm




 
For Students Only
Are You a Student?
Are you under 15 years of age?

Where are you a student?

Commitment Level:

Class:

What is your major?

Is this an Internship for credit?

If yes, how many TOTAL hours required?




References
Please list 3 references that are not your relatives
Personal Reference 1
Name:

Address:

Business/Occupation

Personal Reference 2
Name:

Address:

Business/Occupation

Personal Reference 3
Name:

Address:

Business/Occupation




 
Work History
Please list work history, starting with the most recent, and complete all information boxes for each employer listed.
*volunteer work may be included also*
Employment:

Current or Most Recent Employer
Organization:

Location:

Your Title:

Start Date:

End Date:

Cite 3 Duties or Responsibilities
1.

2.

3.

Past Employment
Organization:

Location:

Your Title:

Start Date:

End Date:

Cite 3 Duties or Responsibilities
1.

2.

3.

Past Employment
Organization:

Location:

Your Title:

Start Date:

End Date:

Cite 3 Duties or Responsibilities
1.

2.

3.




School History
Please list: high school and further or additional education
Education:


Highest Level of Education
Name of School/Institution:

Location:

Degree/Level of Completion:

Other Education
Name of School/Institution:

Location:

Degree/Level of Completion:

High School Education
Name of School/Institution:

Location:

Degree/Level of Completion:





Additional Information
Have you ever been sanctioned or excluded or been the subject of a sanction or exclusion proceeding by Medicare, Medicaid or other federal health care program?

Any questions for us?
 



PLEASE READ CAREFULLY
All of the above statements are true to the best of my knowledge. Any misstatements are sufficient cause for my dismissal. I authorize The Cooley Dickinson Health Care Corporation to verify any information presented in this form and to request statements from references. In the event of my volunteering for the Cooley Dickinson Health Care Corporation, I agree to comply with all of The Cooley Dickinson Health Care Corporation’s rules and regulations as they may be changed from time to time.
Your Name:
Your Email:
Recipient Email:
Your Comments:
Word Verification:
Word Verification