Volunteer Services | Cape Fear Valley Health
Cape Fear Valley Hospital
Volunteer Services

Adult Volunteer Application

First Name:
Middle Name:
Last Name:

Phone:  
Email:

Street Address 1:
Street Address 2:

City:
State:  
Zip Code:  

Occupation:  
Company:  

Business Address:  
Work Phone:  

Previous Experience as a volunteer:
Previous Experience as a paid employee:

Have you ever been employed by Cape Fear Valley Health System?  

Have you any relatives or close acquaintances at Cape Fear Valley Health System?  

Do you have any special training?  

Are you presently enrolled at a school or university?  

How did you hear about the Cape Fear Valley Health System Volunteer Services?

Have you ever been convicted of any criminal offense? A conviction record will not necessarily be a ban on your acceptance as a volunteer. **Examples may include, but should not be limited to: Driving under the influence, worthless checks, assault, driving while license suspended, disorderly conduct, credit card fraud, embezzlement, etc**

Indicate with checkmarks facilities/programs with which you would prefer to volunteer:

What are your reasons for wanting to become a volunteer with Cape Fear Valley Health System?

Please indicate with checkmarks following your preferences:
Days:  




Shifts:  

Number of hours you are available to volunteer each week:

Please indicate with checkmarks your preferences:  


References: To be acceptable can not be your relative and must have known you for at least five years.
Reference Name:

Reference Relationship:

Reference Phone:








Please Read and Submit

I hereby certify that the information given in this application is fully and correctly answered. I understand that any misrepresentation, omission or misstatement, whether intentional or not, is grounds for rejection of my application or termination of my volunteer status if such an occurrence is discovered at a later date. If, in the judgement of the Health System, any information contained herein is found to be untrue, incorrect, or incomplete, I may be refused acceptance as a volunteer or subject to dismissal if already a volunteer. I voluntarily authorize Cape Fear Valley Health System to investigate all information contained in this application. I authorize my present and former employer and/or three references listed on my application to release any information pertaining to my work record and performance to Cape Fear Valley Health System, and release those employers and references from liability unless such information is provided with knowledge that it is false.

I understand that the first fifty hours of volunteer service will be considered as a period of probation. I agree to submit to any physical examination as required by the Health System and, if accepted as a volunteer, I agree to abide by all present and subsequently issued or revised Health System and Volunteer Department policies.

I understand that a criminal check will be conducted.

I further understand that I may be dismissed as a volunteer with or without cause or with or without notice at anytime, at the option of either the Health System or myself. I understand that no representative of the Health System has authority to enter into an agreement with me for volunteer service for any specified period of time, or to make any agreement with me contrary to the foregoing.

Finally, I understand that my application will remain active for no longer than three months from this date, and should I desire to be considered for volunteer service thereafter, I must reapply in the same manner.

Cape Fear Valley Health System is an Equal Opportunity/Affirmative Action Employer. All decisions to accept individuals as volunteers are based on individual qualifications without regard to race, color, sex, national origin, age, religious belief or disability.