Volunteer Submission Form

    First Name*

    Last Name*

    Date*

    Email*

    Address 1*

    Address 2

    City*

    State*

    Zip/Postal Code*

    Home Phone*

    Cell Phone*

    INFORMATION NEEDED FOR CRIMINAL RECORD CHECK

    Date of Birth*

    Sex*

    MF

    EDUCATION

    Highest Grade Completed *

    High SchoolGEDCollege

    Course Of Study

    Other Formal Education and/or Training

    Professional Certifcations

    PERSONAL INFORMATION

    Have You Ever Been Convicted Of A Crime and/or Incarcerated? *

    YN

    If YES, Please Explain:

    REFERENCES

    Please List 3 References (Include Name, Daytime Phone, and Address)

    PLEASE CHECK ANY SUBJECTS AND JOBS OF INTEREST:

    Language InterpreterFaxing and MailingScanning Old RecordsClerical (Typing, Filing, Health Fair Tasks, Etc.)Clinical Work (Patient Intake, Special Health Fairs, Etc.)Split Up/Alternate Days In Clinic To Do Clerical Tasks

    Other

    List Any Special Skills, Hobbies, or Interests That Might Be Helpful:

    Do You Speak Any Languages Other Than English?

    YN

    If YES, which Language?

    Do You Feel You Would Be Unable To Work Objectively With Any Type Of Client?

    YN

    If YES, Please Explain:

    PERSONAL EMERGENCY CONTACT

    Name*

    Relationship*

    Address 1*

    Address 2

    City*

    State*

    Zip/Postal Code*

    Home Phone*

    Work Phone*

    STATEMENT OF AGREEMENT TO PROVIDE VOLUNTEER SERVICES

    I am interested in serving as an ECHC volunteer, I am prepared to receive training and to devote the agreed-upon time to the purpose. I will hold ECHC blameless if I incur injury incident to my work as a volunteer.

    I am donating my services to ECHC for my own personal purposes or pleasure or for civic, charitable and/or humanitarian reasons. I have no expectation of any compensation, pay, fee or other benefits for my volunteer services. I agree that I am not entitled to any wages or any employee benefits to which ECHC employees are entitled. ECHC has not promised me any compensation for any services I render as a volunteer. Finally, ECHC has not promised or suggested that I will receive and employment opportunities, or greater future consideration for an employment opportunity, as a result of my volunteer service.

    As a volunteer, I understand ECHC requires a criminal background check. I grant my permission for such a check. I give ECHC staff permission to conaact my listed references. I also understand that I will sign a confidentiality statement and may need to be immunized, depending on the placement(s) assigned.

    All information in this application form is complete and accurate,

    PLEASE TYPE NAME FOR SIGNATURE *

    DATE OF SIGNATURE *