Volunteer Application

Information

Name *

First

Last

Date of Birth *

DD/MM/YYYY

Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Phone *

Secondary Phone

Occupation

Work Phone

If retired, previous occupation

Emergency Contact

Emergency Contact - Name *

First

Last

Emergency Contact - Relationship *

Emergency Contact - Phone *

Interests

Special skills or interest

Have you done volunteer work previously? *

Where and in what capactiy?

Are you able to volunteer for at least three months? *

Volunteer Service Areas of Interest (check all that apply) *

Preferred Scheduled Days *

Signature

The primary goal of the Volunteer Services Department is to provide organization, direction, and services expansion by maintaining an awareness of hospital needs. We are committed to providing and retaining a competent staff of volunteers who provide supplemental services to hospital personnel, patients, and their families, and visitors of the Hospital. Each volunteer is expected to uphold the philosophy and standards of the Hospital. I am in agreement with the mission, vision, and values of KSB Hospital and will support the goals of the Volunteer Services Department and the hospital. I am also aware that I will not be compensated for my volunteer hours. I also am aware that confidentiality is of utmost importance. Please provide your electronic signature below:

Name *

First

Last

Please note, your volunteer application is contingent upon a successful background check.

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