After filling out this application form, please press the submit button on the bottom of the form to send it to the Appropriate Volunteer areas of Palmetto Health.

* indicates a required field
Volunteer Program Preference

*
ONLY ANSWER THE FOLLOWING IF you have indicated ***PERSONAL TOUCH*** as your preference above:

Are you willing to participate in a training course with a commitment to work in the Personal Touch Department for at least one year folllowing the course? Yes    No

Are you able to work as a volunteer at least four hours each week? Yes    No

Can you participate in an in-service education program 4 to 6 times a year? Yes    No

 
Personal Information
Title: Other:
First Name: *
Middle Name:
Last Name: *
Name prefered for mailing:
Mailing Address: *
Suite/Department:
City: *
State: *
Zip: *
Home Phone: *
Business Phone:
E-mail Address:
Social Security Number:
Fax:
Emergency Contact
First Name: *
Last Name: *
Phone: *
Fax:
Email:
Relationship to Applicant: *
Education
(Check all that apply)
High School Student
High School Graduate
Undergraduate
School:
Degree:
Graduate
School:
Degree:
Employment Status
Employed
Retired
Employer: *
Phone: *
Fax:
Occupation: *
My Employer offers time-off for volunteers
My employer offers a donation matching program.
Unemployed
Student
Volunteer History
Please list any previous volunteer positions: *
What experiences have you had that you feel might help you in your role as a Palmetto Health volunteer? (Include professional experiences as well as special skills, interests and hobbies such as foreign language, typing or public
speaking.) 		*
Have you volunteered with us before? Yes    No
If yes, in what year(s)?
Describe what interests you about becoming a Palmetto Health Volunteer: *
References - Please list 2 people other than relatives who are willing to serve as personal references.
NOTE: Your process will be delayed until your required references have responded to the volunteer office you have indicated.
Reference #1
First Name: *
Last Name: *
Mailing Address: *
City: *
State: *
Zip:
 *
Phone: *
Email:
Fax:
Reference #2
First Name: *
Last Name: *
Mailing Address: *
City:
 *
State: *
Zip: *
Phone: *
Email:
Fax:
Physician Reference
Name: *
Contact info:
(Please include phone, address and fax if available)		 *
Disclaimers and Additional Information
  • I certify that the information I have given on this application is true and complete.
  • I understand that any falsification or omission of information given at any time during my volunteer contract with Palmetto Health may be grounds for deferral or dismissal from volunteer status.
  • All persons or organizations named on this application may provide information about me to the volunteer departments of Palmetto Health, and I hereby release the persons or organizations from any liability for doing so.
  • Although Palmetto Health provides opportunities for volunteers without regard to religion, creed, race, national origin, age, or sex, Palmetto Health is not obligated to provide a volunteer placement to every applicant.
  • If accepted I will comply with all standards and policies of the volunteer department and of Palmetto Health , and I will limit my activities to those for which I have been authorized and trained.
Electronic Signature

By electronically signing our volunteer application you acknowledge this disclosure and you agree to be bound by its terms and conditions.
Name (First, Middle Initial, Last):
 *
Date: *