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Volunteer Application

Your Information

Position you are applying for:
First Name:
Last Name:
Address
City:
State:
ZIP Code:
E-mail Address:
Phone Number:
Date of Birth:		[None]

Emergency Contact Information

First Name:
Last Name:
Phone Number:
Relationship:

Professional Experience

Name of current or most recent employer:
Business Address:
City:
State:
ZIP Code:
Phone Number:
Position Held:
Dates of Employment		From: [None]
		To: [None]

Education

Years of high school completed:		1 2 3 4
Did you receive a diploma:		Yes No
Have you received a GED:		Yes No
Years of college completed:		1 2 3 4
Did you receive a degree:		Yes No
Major:
Other:

References

First Reference Name:
Address:
City:
State:
ZIP Code:
E-mail Address:
Phone Number

Second Reference Name:
Address:
City:
State:
ZIP Code:
E-mail Address:
Phone Number

Volunteer Experience

Organization:
Postion(s):
Date/Length of Service:

Organization:
Position(s):
Date/Length of Service:

Civic/Professional Membership

Organization:
Position(s):
Date/Length of Service:
Your objectives in volunteering at Siteman:		Fulfilling an academic requirement Learn or develop new skills Use existing skills Explore careers Help people living with cancer Meet new people Make use of free time Other
Special Skills:		Word Processing Spread sheet/database Clerical (tpying, filling) Public Speaking Training Providing Tours

Schedule Preferences

Weekday Availability:		Monday Tuesday Wednesday Thursday Friday
Time:		Morning Afternoon Evening
Total hours per week:
How did you learn about the volunteer opportunities at the Siteman Cancer Center?
At which location do you want to volunteer?		Main Campus South County

Background Information

Have you ever been convicted of, or entered a plea of guilty or nolo contendre to, a felony, misdemeanor criminal charge or local nonordinance including one in which you received a suspended imposition of sentence, suspended execution of sentence or any period of probation or parole?

If yes, please specify the offense and the date, place and court:

I certify that all responses on this document are true to the best of my knowledge. I understand that any misrepresentation of information constitutes cause for separation or termination from volunteer services.

Name:

Date:

[None]