First Name*
Last Name*
Date*
Email*
Address 1*
Address 2
City*
State*
AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Zip/Postal Code*
Home Phone*
Cell Phone*
Date of Birth*
Sex*
MF
Highest Grade Completed *
High SchoolGEDCollege
Course Of Study
Other Formal Education and/or Training
Professional Certifcations
Have You Ever Been Convicted Of A Crime and/or Incarcerated? *
YN
If YES, Please Explain:
Please List 3 References (Include Name, Daytime Phone, and Address)
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?
If YES, which Language?
Do You Feel You Would Be Unable To Work Objectively With Any Type Of Client?
Name*
Relationship*
Work Phone*
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 *
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