Personal Information
Age group
Previous Volunteer Experience/ Qualifications
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.
Do you have previous volunteer experience?
Please tell us in which areas you are interested in volunteering:
Availability
Select all availability
During which hours are you available for volunteer assignments.
Emergency Contact
Please list names of two persons, NOT RELATIVES, who have known you for several years (one personal, one professional).

Your Bassett History
Have you ever been employed by Bassett Healthcare Network?
Do you have relatives employed by Bassett Healthcare Network?
Have you or a family member worked, or currently work, for Bassett?
Employment History*
Employment Type
Reason for leaving:
May we contact this employer?

Employment Type
Reason for leaving:
May we contact this employer?

Have you ever been convicted of a crime other than a traffic violation?
*Beginning with most current/ recent
AGREEMENT AND SIGNATURE
Signature of applicant
By submitting this applications, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted into this program, any false statement, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal from the program. I understand that there will be no financial payment for my services. Signing this application in the space provided below indicate that I fully understand the following.
I agree to provide or arrange transportation to and from Bassett Medical Center. I promise to abide by all hospital policies that are included in the employee handbook. I will consider all information confidential, which I may gain, either directly or indirectly concerning patients.