Volunteer Application-SBCH

Application For Membership
Basic Information
Application date
First name
Middle name
Last name
Gender

Home Address
Line 1
E-mail
Line 2
City
State
Zip/postal
Home phone
Work phone
Mobile phone

Emergency Contact
Contact name
Relationship name
Line 1
E-mail
Line 2
City
State
Zip/postal
Home phone
Work phone
Mobile Phone

Reference Checks
Reference 1
Name
Relationship
Organization
Phone
Address
E-mail
City
State
Zip/postal
Reference 2
Name
Relationship
Organization
Phone
Address
E-mail
City
State
Zip/postal
Reference 3
Name
Relationship
Organization
Phone
Address 1
E-mail
City
State
Zip/postal

Are you currently employed?
Where are you currently employed?
Are you attending school?
Where are you attending school?
Have you volunteered at Cottage Health System before?
If yes, did you complete your 100 hours?
If yes, why did you leave?

Areas Of Interest
Job preferences
What area is your first choice?
What area is your second choice?
What area is your third choice?

Skills
Other skills, education, or special training:

Briefly describe why you would like to volunteer at SBCH
I am interested in volunteering for the following reason(s):
Describe any experience you have working with or supervising a group of individuals. What are some of your struggles and successes?
Describe any additional experiences you have that may help you in volunteering at CHS.
CHS supports a culture of Patients First. Everything we do is on behalf 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?

Availability
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8am - 12pm
8am - 12pm
8am - 12pm
8am - 12pm
8am - 12pm
8am - 12pm
8am - 12pm
12pm - 4pm
12pm - 4pm
12pm - 4pm
12pm - 4pm
12pm - 4pm
12pm - 4pm
12pm - 4pm
4pm - 8pm
4pm - 8pm
4pm - 8pm
4pm - 8pm
4pm - 8pm
4pm - 8pm
4pm - 8pm
8pm - 12am*
8pm - 12am*
8pm - 12am*
8pm - 12am*
8pm - 12am*
8pm - 12am*
8pm - 12am*
* 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", orreferral to any diversion program. Please do list all other convictions, including driving under the influence. Providea full explanation of the conviction or pending criminal charges. A conviction or pending charges will not necessarilydisqualify you from volunteering. Each situation will be considered on its own merits. Falsifying your application byfailing to disclose relevant information in response to this question, however, will disqualify you from volunteering.
If yes, please list / describe:
Are you able to perform the essential duties of a volunteer with or without reasonable accommodation?
Cottage Health System is an Equal Opportunity Employer. CHS 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 SBCH I 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 Santa Barbara Cottage Hospital 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 Cottage Health System 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.
Applicant Signature:
Date:
If applicant is under age 18, a parent or guardian signature is also required:
Date:
Parent/Guardian Signature: