Susquehanna Health Volunteer Services Application Form

Please complete all of the information requested on the application.
All fields in red must be completed.

Personal Information
  Mr.   Mrs.   Ms.   Miss
  First Name
  Middle Initial
  Last Name
  Home Phone
  Cell Phone
  Work Phone
  E-Mail Address

Address
  Street/Address
  City
  State
  Zip

Education
 High School
Last Year Completed Grade 
Did You Graduate? Yes No

 College/Trade
Years Completed
Did You Graduate? Yes No
Degree/Certificate
Other Training, certification or degree

SH Experience
Have you ever worked or volunteered for Susquehanna Health? Yes No

If yes, please complete the following.

Under what name did you work or volunteer?
Which Department?
Dates of service
Reasons for leaving
Supervisor's name and job title

Volunteer Interests

Write in available times to serve. Please give specific times.

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Campus preference Divine Muncy Williamsport

List your hobbies, special interests and/or talents

What do you want to gain from your volunteer experience?

Explain any requirements or limitations you want to have considered in a volunteer assignment


Employment/Volunteer History
Name of present employer
Employer Address
Immediate supervisor
Telephone Number
Description of responsibilities
Previous employment and/or other volunteer experiences
Dates
Paid Volunteer
Immediate Supervisor
Telephone Number
Description of responsibilities
Reasons for leaving

Legal
Have you ever been convicted of a Felony?
Conviction of a crime does not necessarily disqualify an applicant.		 Yes No
Are you currently doing community service as a result of a judge's order? Yes No

Emergency Information
1. Name
Relationship
Home Telephone Number
Work Telephone Number
2. Name
Relationship
Home Telephone Number
Work Telephone Number

References
1. Name
Relationship
Telephone Number
2. Name
Relationship
Telephone Number

Please read and acknowledge the following statement.

I authorize investigation of all statements contained in this application. By submitting this application form, I certify that he information given is true. I understand that misrepresentation or omission of facts called for herein will be sufficient cause for cancellation of consideration for volunteering or dismissal from Susquehanna Health Volunteer program if I have become a volunteer.

I hereby acknowledge that I have read the above statements, understand them and agree with them.