Requirements: Must be 21 or older, complete background check, TB test, volunteer orientation, flu shot (depended on season)
Adult Volunteer And Background Check – Fillable Application 4.16.2021
First Name *
Last Name *
Address Line 2
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Mobile Phone *
Prefered Contact *
Emergency #1 *
Do you have any physical or medical conditions which will limit your ability to perform volunteer service or will require any special accommodation? *
If yes, please explain *
How did you hear about our volunteer program? *
Approximately how many hours per month are you willing to volunteer? *
Why do you wish to volunteer? *
In what capacity do you wish to volunteer? *
Work Status *
If employed, where and in what capacity
Previous volunteer / community work
Level of education completed *
HS DiplomaGEDUndergraduateMastersPhDSome College
If enrolled in college, where?
Other special skills
Hobbies, interests, activities
Please place a "Y" in available work areas *
Do you prefer *
Patient ContactNo Patient ContactClericalOther
Is there a specific area you would like to request? *
Are you willing to be called with special projects? *
A background check will be conducted on all adult volunteer applicants. CTC conducts criminal history checks on every volunteer. Please note that conviction of a crime is not an automatic disqualification. Failure to disclose or provision of false information will result in the disqualification and/or termination of the application.
No volunteer at CTC will discriminate against an applicant for volunteering or a fellow volunteer because of race, creed, color, religion, sex, national origin, ancestry, age or any physical or mental disability."
Is your volunteer service intended to satisfy court-ordered community service? *
**Please attach a copy of your driver’s license and a copy of your food handler’s card, if applicable.** Professional Volunteers please attach applicable licensure or certifications.
Should I be accepted as a CTC Volunteer, I agree to:
Maintain the confidentiality of all information which I may obtain directly or indirectly concerning patients, physicians, volunteers or staff.
Not seek confidential information in regard to any patient.
Uphold the Mission, Vision, Values, and Code of Conduct of CTC.
Make every effort to fulfill my volunteer commitment.
I certify the statements made in this application are true and correct and given voluntarily. I understand that my time and services are donated to CTC without contemplation of future employment and also understand that I will not be paid for my services as a volunteer. Prior to the onset of serving as a volunteer, I
understand that I will be required to complete an Orientation, Occupational Health Screening, and additional training that a service assignment may require.
I am aware that the misrepresentation and/or withholding of information may result in the rejection of this application or cause my discharge if discovered after volunteer service commences.
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