Fillable JUNIOR VOLUNTEER APPLICATION WHEELING HOSPITAL

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JUNIOR VOLUNTEER APPLICATION WHEELING HOSPITAL

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For Office Use Only:
Application Date: ______________
Interview Date: ______________
Orientation Date: ______________
Background Check: ______________
WHEELING HOSPITAL
JUNIOR VOLUNTEER APPLICATION
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Social Security Number:
__________-__________-_________
E-Mail Address: Date of Birth: MM/DD/YY
___________________________________________________________ _________/_________/___________
Contact in Case of Emergency
Name: Relationship:
Home Phone: Cell Phone: Work Phone:
Educational and Work Experience
Circle Last Grade Completed:
High School: 9 10 11 12
Career Interest:
Preferences
Check the appropriate boxes for availability:
o Helping
Patients
o Retail
o Computer
o Organization
o Office
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
Morning
Afternoon
Evening
Please circle your volunteer preference: Summer Only Year Round
Are you required to Volunteer? _________Yes _________No
If yes, explain the details:
How did you hear about our Volunteer Program?
Have you ever been convicted of, plead guilty, no contest or nolo contendere to a misdemeanor or
felony?
________Yes ________No
Please be aware that a criminal conviction will not necessarily be a bar to volunteering. Failure to
honestly and completely answer this question will result in discontinued consideration of the volunteer
program application.
If YES, please indicate:
County: _________________ State: _________________ Date: _________________ where convicted.
Nature of offense committed and the sentence or penalty imposed on you:
I certify that the information given on this application is true and complete to the best of my knowledge.
I authorize the organization or person named in this application to give any information regarding my
employment, education or records. I release said organizations or persons from all liability for any
damage for issuing this information.
I understand that falsification or misinformation or omission of information herein may be cause for
denial of or termination of volunteer service. I further authorize a background check with the
appropriate agencies (i.e., consumer reporting agency, federal exclusion lists, etc.).
This organization is not obligated to provide a volunteer placement nor are you obligated to accept the
volunteer position offered.
Personal or Professional References ( Exclude Relatives)
Name:
Phone:
Address:
City:
State:
Zip Code:
Name:
Phone:
Address:
City:
State:
Zip Code:
Your Signature Indicates Your Approval For Reference Checks
Applicant’s Signature:
Parent’s Signature:
Wheeling Hospital Inc. believes in equal opportunity and does not discriminate against any individual in
accordance with the requirements of local, state and federal law.
Please return to: Wheeling Hospital
Department of Volunteer Services
One Medical Park
Wheeling WV 26003
Telephone: 304-243-3303
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JUNIOR VOLUNTEER APPLICATION WHEELING HOSPITAL

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Completed 5 June 2021

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