Volunteer Application

Please fill out this form and submit. If you have any questions please contact the below.

Volunteer Services, Cottage Health
400 W. Pueblo St, PO Box 689
Santa Barbara CA 93102

volunteering@sbch.org
(805) 569-7357 phone
(805) 569-7397 fax

Which hospital would you like to volunteer at?

Volunteer Information

Mr./Mrs./Ms.
Last name
First name
Spouse's first name
Street Address
City
State
ZIP
Phone (Home)
Phone (Mobile)
E-mail
Gender
Are you currently employed? If so, where?
Emergency Contact name
Are you attending school? If so, where?
Emergency Contact Phone (Home)
Have you volunteered at Cottage Health before?
If yes, did you complete your 100 hours?
If yes, why did you leave?

References

Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone

Please check the areas that interest you.

Santa Barbara Cottage Hospital Service Areas
Santa Ynez Valley Cottage Hospital Service Areas
Goleta Valley Cottage Hospital Service Areas
What area is your first choice?
What area is your second choice?
What area is your third choice?
Office / Technical Skills
Creative / Personal Skills
Accounting
Board and card games
Cashier / sales
Customer service
Excel Beg
Excel Int
Excel Adv
Art / drawing / painting
Word Beg
Word Int
Word Adv
Food service
Humor / stories
PowerPoint Beg
PowerPoint Int
PowerPoint Adv
Knitting
Filing
Music / singing
Mail room
Photography
Office equipment (10-key)
Sewing / needlepoint
Telephones
Typing WPM:
Additional languages
Other skills, education, or special training.

Briefly describe why you would like to volunteer.

I am interested in volunteering for the following reason(s):
Describe any experience you have working with or supervising a group of individuals.
What were some of your struggles and successes?
Describe any additional experiences you have that may help you In volunteering at CH.
CH supports a culture of Patients First. Everything we do is on behalf of the best interests of our patients grounded in our values of excellence, integrity, and compassion.
What does patient satisfaction mean to you?
How did you hear about us?

Please mark the times you are available to volunteer.

SUN
MON
TUE
8 a.m. - 12 p.m.
8 a.m. - 12 p.m.
8 a.m. - 12 p.m.
12 p.m. - 4 p.m.
12 p.m. - 4 p.m.
12 p.m. - 4 p.m.
4 p.m. - 8 p.m.
4 p.m. - 8 p.m.
4 p.m. - 8 p.m.
8 p.m. - 12 a.m. (ED Only)
8 p.m. - 12 a.m. (ED Only)
8 p.m. - 12 a.m. (ED Only)
WED
THU
FRI
8 a.m. - 12 p.m.
8 a.m. - 12 p.m.
8 a.m. - 12 p.m.
12 p.m. - 4 p.m.
12 p.m. - 4 p.m.
12 p.m. - 4 p.m.
4 p.m. - 8 p.m.
4 p.m. - 8 p.m.
4 p.m. - 8 p.m.
8 p.m. - 12 a.m. (ED Only)
8 p.m. - 12 a.m. (ED Only)
8 p.m. - 12 a.m. (ED Only)
SAT
8 a.m. - 12 p.m.
12 p.m. - 4 p.m.
4 p.m. - 8 p.m.
8 p.m. - 12 a.m. (ED Only)
Have you been convicted of a misdemeanor or felony, or are there pending criminal charges against you? Please do not list any marijuana-related conviction more than two years old, any conviction that is "sealed" or "expunged" or referral to any diversion program. Please do list all other convictions, including driving under the influence. Provide a full explanation of the conviction or pending criminal charges. A conviction or pending charges will not necessarily disqualify you from volunteering. Each situation will be considered on its own merits. Falsifying your application by failing to disclose relevant information in response to this question, however, will disqualify you from volunteering.
Yes
No
If Yes, please list / describe:
Are you able to perform the essential duties of a volunteer with or without reasonable accommodation?
With Reasonable Accomodation
Without Reasonable Accomodation
Cottage Health (CH) is an Equal Opportunity Employer. CH does not discriminate on the basis of race, national origin, religion, sex, sexual orientation, age, disability, or any other category protected by applicable federal, state,or local laws.

I understand and agree that in performing my service as a volunteer of CH must hold patient and other confidential information in confidence. I understand that any violation would be grounds for disciplinary action.

I am volunteering my services to CH solely for my personal purposes or benefit without promise or expectation of compensation or benefits. I agree to serve as a volunteer for a 6-month commitment for 100 cumulative hours of service.

I declare that all of the statements in this application are true, correct, and complete to the best of my knowledge and authorize CH to investigate any statements in determining my eligibility for a volunteer position.I understand that falsification or material omission on this application is grounds for rejection of my application or my dismissal from volunteering. I acknowledge that the continuation of my volunteer position is at the consent of the volunteer and the hospital. This volunteer position is terminable at will by either party.
By typing your name below you agree to the above conditions.
Applicant Signature
Applicant Signature Date
If applicant is under age 18, a parent or guardian signature is also required:
Parent/Guardian Signature
Parent/Guardian Signature Date