:: Highlands Regional Medical Center ::

*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
Skill Type	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:

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 DD/MM/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

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- 8/19/2008

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- 8/15/2008

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- 8/15/2008

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- 8/14/2008

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