Bon Secours- Baltimore Volunteer Application

First Name

Last Name

Preferred Name

Street Address

Address Line 2

City

State

Postal / Zip Code

Birth Date

Highest Level of Education

GEDHigh SchoolAssociates DegreeBachelor's DegreeGraduate School

Preferred days to volunteer. Please select all that apply.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Preferred times to volunteer. Please select all that apply.

MorningAfternoonEvening

Are there certain hospital departments or specific tasks that interest you?

Please list your skills/interests and any special training. Include previous volunteer experience.

Have you ever pled guilty or been convicted of a crime(s) other than minor traffic violations?

YesNo

Please explain

Please list any health concerns/allergies.

Emergency Contact

Emergency Contact Name

First

Last Name

Last

Relationship

Emergency Contact Phone

Employment History

If you have been employed in the last five years, please complete the table below. Please skip if you have not been employed within the last five years. Include both full and part-time work.

Please share any relevant details about your employment history including: name, address and phone number of employer, duties performed during time of employment and reason for leaving.

References

Please list two references. Please include non-family members. For example: clergy, friend, supervisor, teacher, etc.

Reference #1 Name

First

Last Name

Last

Reference #1 Phone Number

Street Address

Address Line 2

City

State

Postal / Zip Code

Reference #1 Occupation

Relationship to Reference #1

How long have you known Reference #1?

Reference #2 Name

First

Last Name

Last

Reference #2 Phone Number

Street Address

Address Line 2

City

State

Postal / Zip Code

Reference #2 Occupation

Relationship to Reference #2

How long have you known Reference #2?

I have completed the above information to the best of my ability and understand that any falsification of the information provided may prohibit me from volunteering. As a volunteer, I agree to hold confidential all information to which I may have access. This includes, but is not limited to, information on current, former or prospective patients and employees. Disclosure of such information to unauthorized persons is prohibited and may result in my dismissal from the volunteer program and may have additional legal consequences.

Check if you agree.

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