Advocate Lutheran General Hospital - Volunteer Profile Application



	1775 Dempster Street • Park Ridge, Illinois 60068 • (Main) 847.723.2210 • TDD

Volunteer Program
at Advocate Lutheran General Hospital

General Information

How to Volunteer / Application

Eligibility & Benefits

Assignment Opportunities

Mission, Values, Philosophy

Volunteer Profile Application

Please fill out this form as completely as possible.
Required information is marked with an asterisk (*). If you have any questions please call 1.847.723.6105.

Personal Information

Title:	Miss Ms. Mrs. Mr.
Name:*
Street address:*	Apt.:
City:*
State:*	ZIP:*
Home phone:*
Other phone:
E-mail address:*
Date of birth:	/ /
Current employer/school:
Work phone:

Education
High School	Some College
Undergrad Degree	Graduate Degree
Trade School

Emergency Contacts
Name:
Relationship:
Phone:

Name:
Relationship:
Phone:

Previous Volunteer Experience

Which area would you like to volunteer? (please select at least two)
Patient services	Guest services
Flower shop/gift shop	Special services
Clerical services	Child life department

Do you have any medical limitations on the type of volunteer work you can perform?
If yes, please explain:

When are you available to volunteer?
	Morning	Afternoon	Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

How did you learn about volunteer opportunities at Advocate Lutheran General Hospital?
Friend Employer School
Newspaper Volunteer Fair/Exhibit Advocate Website
Other Website
Other

Personal References
Name:
Occupation:
Phone:

Name:
Occupation:
Phone:

Have you ever been convicted of a crime, other than a traffic violation or misdemeanor, in the last seven years?*
yes no

If yes, please explain:

I hereby affirm that the information provided on this application is true and complete to the best of my knowledge, and agree to have any of the statements checked by the organization or its representatives. I understand that providing any false or misleading information or any omissions may disqualify me from further consideration as a volunteer and may result in my immediate termination even if discovered at a later date.

I authorize representatives of Advocate Lutheran General Hospital to conduct a thorough investigation of my activities, and authorize all references provided in this application, as well as all other individuals, whom the Organization or its representitives may contact, to provide all information they have about me. Furthermore, I agree to cooperate in such investigation, and release from all liability or responsibility of the Organization, all persons and entities acting on its behalf, and all persons and entities requesting or suppling such information.

I have read this disclaimer.*
Date: / /

http://www.advocatehealth.com

1.800.3.ADVOCATE / TDD 630.990.4700
También tenemos representantes que hablan español.