WI Rapids Volunteer Application Form

Volunteer Application Form

Aspirus Wisconsin Rapids Hospital & Clinics
Application Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone/Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
Driver's License Number
Have you ever been employed at Aspirus Wisconsin Rapids Hospital?
Emergency Contact

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about our volunteer program?
Business, professional or volunteer experience?
Example: computer skills, knitting, former RN, etc.
Please list any special skills and/or hobbies
Example: foreign language, arts, reading, etc.

REFERENCES

Please list two NON-RELATIVE references.
Reference 1

First NameLast Name
Relationship
Email
example@example.com
Reference 1 Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Contact Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2

First NameLast Name
Relationship
Email
example@example.com
Reference 2 Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Contact Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.

I understand and agree that submitting this application form does not automatically register me as an Aspirus Wisconsin Rapids Hospital and Clinics volunteer and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures, completion of background information disclosure form, and health screenings before I may begin volunteering. By signing this form, I attest that the information I have provided on this form is true and accurate.
Signature Date Hidden

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Volunteer Application Form