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*Name:  
*Address:  
City/Town:  
State:     Zip Code:  
Country:
*Home Telephone Number:  
Work Telephone Number:
*E-mail Address:    
Date of Birth:  
(All applicants must be at least 18 years old)
Gender:      
How did you learn about the volunteer program?
Please describe yourself. What are your best qualities, your limitations?
Are you flexible, energetic, enthusiastic and organized?
Are you currently facing any significant physical or emotional challenges?
Why do you want to volunteer at Highlands Regional Medical Center?
What are your concerns in coming to volunteer at HRMC?

Work Skills

Skill Type Level of Skill
None Good Strong
Computer  
General Office  
Guest Services  
Marketing  
Phone Skills  
Other Skills  


Most of the volunteer work involves a fair amount of physical labor. You may be involved in lifting heavy objects as well as being on your feet for long periods at a time. Would you be able and willing to perform such tasks? (Please explain why or why not)
Ideally, what job(s) would you like to do as a volunteer?
Please describe your present state of health, noting any physical or psychological conditions.
Are you currently on any prescription medication?
If yes, please give the name of the medication and the condition for which it is prescribed.
Have you ever been tested positive for tuberculosis or hepatitis?


Employment Experience

Start with your present or last job. Include any job-related military service assignment and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status. You may attach a resume if you like.

Employer:
From: To:
Address:
City: State: Zip:
E-mail:
Telephone Number:
Job Title:
Work Performed
Reason for Leaving:
Further Experience:
 
Volunteer Experience: (Please list previous volunteer work performed)
Have you ever been convicted of a felony or misdemeanor? If yes, please explain.
(Conviction does not necessarily disqualify an applicant from volunteering)



  Reference 1 Reference 2
Name
E-Mail


Agreement & Acceptance

I affirm that the information contained in this application is complete and correct. I also understand that submission of this application does not guarantee me acceptance into a volunteer term(s) and that I will be contacted for a phone interview after my submission of this application.
I agree

Date of Application


MM/DD/YYYY




Please feel free to contact us anytime for more information.

Email
mvance@hrmc.org

Address
Highlands Regional Medical Center
P.O. Box 668
Prestongsburg, KY 41653
Attn: Melissa Vance

Fax
606-886-7453