Adult Volunteer App

Personal Information

Please select the Jackson facility where you wish to apply.

* First name

* Family/last name

* DOB

* Address

Apt, Suite, or Unit #

* City

* State

* Zip/postal

* Phone (Home)

Phone (Business)

* Phone (Mobile)

* E-mail

Additional languages you speak fluently (select all that apply)

* Drivers License

* Social Security Number * last 4 digits?

Have you lived in Florida for the past seven (7) years?

If not please list...

* Present/Former Employer

* Position Held

* Work Experience

* Volunteer Experience

* Length of Service

* Reason for Leaving

* Why did you choose to volunteer?

How did you hear about Jackson?

Can you meet the 150 hour requirement?

Placement Preferred

Availability (Jackson Main Campus Monday through Friday only)

Sunday

8am-Noon

Noon-4pm

4pm-8pm

Monday

8am-Noon

Noon-4pm

4pm-8pm

Tuesday

8am-Noon

Noon-4pm

4pm-8pm

Wednesday

8am-Noon

Noon-4pm

4pm-8pm

Thursday

8am-Noon

Noon-4pm

4pm-8pm

Friday

8am-Noon

Noon-4pm

4pm-8pm

Saturday

8am-Noon

Noon-4pm

4pm-8pm

* Emergency contact

* Relationship

* Emergency Contact Phone

Are you affiliated with any community organization?

If so, please select the Community Program you are affiliated with

Please enter names of two (2) personal contacts NOT related to you. Please note you will be asked to submit a letter of reference.

* Contact 1

* Contact 2

Have you ever volunteered at Jackson Health System?

Do you have any relatives presently employed by JMH/PHT?

If yes, please list name(s) and department(s)

* Please list your Hobbies/Skills

Do you have any pending court cases?

I agree to abide by the policy/rules set forth by the Public Health Trust and the Volunteer Resources Department at Jackson Health System. I will attend orientation, complete Health Office requirements and all necessary training. I will observe the Volunteer Dress Code, Code of Ethics and agree to keep all patient information confidential. I understand that I will not be paid for my volunteer services. I understand that failure to abide by the above mentioned are grounds for inmediate dismissal.

I authorize investigation of all statements herein and release Jackson Health System/Public Health Trust for liability in connection with same. I also understand that false, misleading or omitted information herein may result in dismissal regardless of the time of discovery by Jackson Health System/Public Health Trust.

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