Name:

Email Address:

Physical Address:
Please include Street, City, State and Zip.

Phone:


Date of birth:

Social Security Number:

Spouse's first name:

In case of emergency, notify:

Name of physician:

Check educational background:
High School    College    Business School    Degree
Other

Have you ever been a volunteer? Please choose Yes No

If so, where did you volunteer?


Other professional or business experience:


What are your hobbies and talents?


What are your other responsibilities?
(small children, job, other volunteering, etc.)


Do you have a preference as to the area of volunteer service placement?


Our usual shifts are 9:00 a.m. to 1:00 p.m., from 1:00 p.m. to 5 p.m., and from 5:00 p.m. to 8:00 p.m. The volunteer usually works one shift of four hours per week. What days and hours are you available for regular service?



References: (These should be a member of the WGHS Auxiliary, a physician, clergy or other respected member of the community.)

Reference #1 name:


Reference #1 phone:

Reference #1 address:


Reference #2 name:


Reference #2 phone:

Reference #2 address:


Have you ever been convicted of a criminal offense other than a minor traffic violation?
Please choose Yes No
If yes, please give all of the facts regarding your conviction. Note: A conviction will not automatically disqualify you from a placement.

West Georgia Health System is committed to maintaining a healthy environment and is a tobacco/smoke-free facility. Policy prohibits use of tobacco in any area of the Health System.

Checking "I agree" below indicates your approval for us to check references and contact your physician regarding your physical and emotional health.

WGHS is not obligated to provide a placement, nor are you obligated to accept the position offered. Opportunities for volunteers are provided without regard to race, color, religion, sex, citizenship, national origin, age, or disability.

I agree to the above terms.