For Community

Adult Volunteer Application

Volunteer Information

First Name
Last Name
Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Email Address

Emergency Contact Information

In case of Emergency, notify
Relationship
Address
City
State
Zip Code
Phone

Education

High School / GED
Year Completed
College
Year Completed
Degree
Post Grad
Year Completed
Degree
Other Training
Medical Training
Special Skills / Training / Certifications

Employment

Current
Position
Supervisors Name
Employment Phone
Please check one

Volunteer Information

Have you ever been convicted or pleaded guilty to a crime? (misdemeanor or felony)
If yes, explain for each conviction, nature of offense, date(s) of conviction, sentence, and type(s) of rehabilitiation, if any. Please include major traffic violations. (Note: A conviction will not automatically bar you from volunteering)
How did you hear about our program?
Please specify
Reasons for Volunteering
Please specify
What interests you the most (please check all that apply):
Volunteer areas that interest you
What day(s)/time(s) are you available to volunteer? (please check all that apply)
Have you ever been a volunteer or employee of CaroMont Health, Gaston Memorial Hospital, or any subsidiaries?
If yes, please list all previous positions, locations, supervisors and year

CaroMont Health is committed to work force diversity and does not discriminate against qualified persons on the basis of race, color, religion, sex, national origin, age, disability, veteran status or other factors identified and protected by federal, state or local legislation. This application will be active for 3 months, after that time a new application will be required.

  • I authorize CaroMont Health to make any inquiry or investigation deemed necessary to consider my volunteer application. This may include contacting former employers and criminal records check. I understand that conviction of a crime will not automatically bar my volunteering. I may still be eligible for volunteering if CaroMont Health determines my conviction could have no bearing to the volunteer position for which I am applying.
  • I have completed this application to the best of my ability and acknowledge that any falsehoods made on this application will be grounds for immediate termination or hereby eliminating me from consideration for volunteer work for CaroMont Health.
Signature (Please type your name acknowledging that you agree)
Date September 26, 2016

Volunteer Acknowledgement Form

I hereby acknowledge and proclaim that I am volunteering for CaroMont Health, and agree to the following statements:

  1. I am volunteering freely and without pressure or coercion, direct or implied, from anyone, including, but not limited to, my employer;
  2. I am volunteering and performing services for civic, charitable or humanitarian reasons;
  3. I am volunteering and performing services without promise, expectation or receipt of compensation (wages, benefits, etc.) for services rendered; if I am reimbursed for expenses I incur for or while doing volunteer work, this will not create an expectation of compensation for the services I perform.
  4. I hereby acknowledge that my request to perform unpaid volunteer work is a voluntary decision on my part. I understand that there is not and will not be any employment relationship or expectation of an employment relationship associated with my performance of volunteer services.
  5. I understand that I am free to stop performing volunteer work for CaroMont Health at any time. I am under no obligation to continue performing volunteer work for any length of time.
  6. I understand that I am not eligible for benefits based on my volunteer activities, including health insurance, worker's compensation, disability or other Agency, state or federally sponsored benefits.
  7. I understand that my volunteer duties may be subject to change depending on my circumstances and the needs of the program or department.

I understand and agree that I have carefully read and fully understand the contents and legal effect of all provisions of this agreement; knowingly and voluntarily agree to all terms in this agreement; and knowingly and voluntarily intend to be legally bound by the same.

Signature (Please type your name acknowledging that you agree)
Date: September 26, 2016