Volunteer Application-Ballad Health • Pre-Health Program • Emory & Henry

Please complete all portions of the Application. Items marked with an asterisk (*) are required.

All fields marked with asterisk (*) are required.

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Name*

Last, First, Middle

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Address*

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Month/ Year you began at E&H*

i.e. August 2018

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Telephone Number*

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Email*

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Birthdate

Month/Day/Year

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Emergency Contact*

(Name, Relationship)

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Emergency Contact Phone*

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Work Experience*

Please describe any previous work experience(s)

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Volunteer Experience*

Please describe any previous volunteer experience(s)

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Hobbies/Interests/Skills*

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Languages*

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Have you ever volunteered at a Ballad Health Facility?*

Yes

Unsure

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Are you required to volunteer?*

Yes

Unsure

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If yes, by whom?

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Do you have relatives employed at JMH?*

Yes

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If yes, list the relation and area relative presently works

(e.g. Mother- critical care unit)

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How did you hear about the volunteer program at JMH?*

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Days/Hours Preferred for volunteering*

(i.e. Monday 11:00am -3:00pm; Wednesday 1:00-4:00pm, etc)

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Do you use tobacco products*

(BalladHealth policy restricts the hiring/volunteering of Tobacco Users)

Yes

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Have you ever been convicted of a criminal offense?*

Falsification of this or any other information on the application is grounds for immediate termination from the volunteer program.

Yes

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If yes, please explain

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Do you have any physical limitations or are under any course of treatment which might limit your ability to perform certain types of work?*

Yes

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If you are considering volunteering as a Courtesy Cart driver, you must be a minimum of 21 years of age, have a current valid driver's license, and have had no driving violations within the past one year.

Please provide the state of issue and expiration date of driver's license, if considering a courtesy cart role.

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Name of person providing character reference*

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Email/ phone for person providing the reference*

Link (required)