CHI St. Alexius Health Bismarck Volunteer Form

Personal Information

First Name *

Middle Name *

Last Name *

Address *

Address 2

Email *

Zip Code *

Employer

Phone (day) *

Phone (Eve)

Phone (cell)

Occupation

A copy of valid government-issued photo identification must be attached to complete this application. *

More information

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png bmp pdf.

Birthdate *

Month

Day

Year

Please list the volunteer position(s) of interest to you

When are you available to volunteer?

Volunteers typically serve two to four-hour shifts, scheduled according to the department’s need and the volunteer’s availability. You are asked to commit at least 50 hours of service in a six-month period.

Shift Frequency

Weekly

2x/month

1x/month

Are you available to substitute on short notice?

Yes

Are you available to volunteer on holidays?

Yes

Please list any related paid or unpaid experience:

What do you hope to gain from your experience as a CHI St. Alexius Health volunteer?

What would you never want to be asked to do as a volunteer?

Do you speak any foreign languages?

Where did you first learn about volunteer opportunities here?

Emergency Contact

Name *

Relationship *

Phone (day) *

Phone (eve)

References

Please list two people, not related to you, who can serve as references.

Reference 1

Name *

Address *

Relationship *

Phone *

Email *

Reference 2

Name *

Address *

Relationship *

Phone *

Email *

Conviction Record

Are you currently named as defendant in a criminal proceeding for mistreatment, neglect, or abuse of any person or a misappropriation of property? *

Yes

Have you ever been convicted of any other felony or misdemeanor? *

Yes

Please explain

A criminal conviction record does not by itself constitute an absolute bar to volunteering. The nature of the conviction will be examined on a case-by-case basis, including subsequent rehabilitation, and will be considered in relation to the responsibilities of the position sought in making each employment decision.

As a condition of volunteering, I give permission for CHI St. Alexius Health to conduct a background check on me, which may include a review of the sex offenders’ registries, references, and criminal history records. I understand that my appointment is conditional upon the information provided. I hereby release and hold harmless from liability CHI St. Alexius Health, its officers, employees, and volunteers, as well as any person or organization that may provide information to CHI St. Alexius Health.

I also understand that this is an application for a volunteer position only. CHI St. Alexius Health is not obligated to provide placement, nor is the applicant obligated to accept the position offered.

The information that I have provided may be verified by contacting persons or organizations named in this application, or by contacting any person or organization that may have information concerning me, or by conducting the background checks described above. By signing this application, I verify I have read the information disclosed and certify that it is true and correct.

Signature *

Yes

Parent/Guardian signature if applicant is under 18 years of age

Yes

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Please list two people, not related to you, who can serve as references.

General Information