Adult Volunteer Application

First Name *

Middle Name

Last Name *

Address *

Address Line 2

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands

Zip *

Home Phone

Mobile Phone *

Prefered Contact *
HomeMobile

Gender *
MaleFemale

Email *

First Name *

Last Name *

Relationship *

Emergency #1 *

Emergency #2

Do you have any physical or medical conditions which will limit your ability to perform volunteer service or will require any special accommodation? *
YesNo

How did you hear about our volunteer program? *
SelfWebsiteEmployeeVolunteerSchoolAdvisorOther

Work Status *
StudentHomemakerRetiredEmployedSeeking Employment

If employed, where and in what capacity

Previous volunteer / community work

Level of education completed *
HS DiplomaGEDUndergraduateMastersPhDSome College

If enrolled in college, where?

Major

Languages

Other special skills

Hobbies, interests, activities

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? *
YesNo

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? *
YesNo

**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.

ID Upload

Volunteer Commitment to Confidentiality and Service

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.

Signature *
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Date *