Volunteer Application

It is the intent of the CDHCC to conform to Federal and State Laws pertaining to non-discrimination.

Basic Information

Salutation:
Mr.  Miss  Ms.  Mrs.
Full Name:
Home Phone:
Cell Phone:
Email:
Address:
Address:
Optional
City:
State:
Zip:

 

Emergency Contact

Full Name:
Relationship to You:
Phone:
Email:
Address:
Address:
Optional
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?
Yes No
Were you ever employed by CDHCC?
Yes No
Are you a member of RSVP?
Yes No
Have you ever volunteered at CDH before?
Yes No

 

Your Availability:

Please note best days and times.

Mon. Tue. Wed. Thurs. Fri. Sat. Sun.
8am - Noon
Noon - 4pm
4pm - 8pm

 

For Students Only

Are You a Student?:
Yes No

 

References:

Please list 3 references that are not your relatives
Click the arrow to expand each reference section.

  • Personal Reference 1

    • Name
    • Address
    • Business/Occupation

  • Personal Reference 2

    • Name
    • Address
    • Business/Occupation

  • Personal Reference 3

    • Name
    • Address
    • Business/Occupation

 

Work and School 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*
Click the arrow to expand each employment/education section.

Employment:
I have not been employed before.

  • Current or Most Recent Employment

    • Organiztion
    • Location
    • Your Title
    • Start Date    End Date 
    • Cite 3 Duties or Responsibilities
      • 1.
      • 2.
      • 3.

  • Past Employment

    • Organiztion
    • Location
    • Your Title
    • Start Date    End Date 
    • Cite 3 Duties or Responsibilities
      • 1.
      • 2.
      • 3.

  • Past Employment

    • Organiztion
    • Location
    • Your Title
    • Start Date    End Date 
    • Cite 3 Duties or Responsibilities
      • 1.
      • 2.
      • 3.
Education:

Please list: high school and further or additional education

  • Highest Level of Education

    • Name of School or Institution
    • Location
    • Degree or Level of Completion

  • Other Education

    • Name of School or Institution
    • Location
    • Degree or Level of Completion

  • High School Education

    • Name of School or Institution
    • Location
    • Degree or Level of Completion

 

Additonal Information:

Have you ever been the subject of any disciplinary or corrective action or conduct or performance by any authorized oversight agency?

Yes No

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?

Yes No
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.