THE HICKMAN VOLUNTEER APPLICATION

The Hickman follows the principles of the Religious Society of Friends. It provides equal opportunities for all qualified persons regardless of race, color, sex, sexual preference, age, religion, national origin, or limited handicap. The Hickman’s firm policy is to disregard these factors during the evaluation of volunteers. As a volunteer, you must treat others in a nondiscriminatory manner.

Please fill out the application and click "send".

Fields marked (*) are required
PERSONAL INFORMATION
*Name: *First:
Please enter your first name. 		*Last:
A value is required.
Address: Street:
City: State: Zip:
Contact Phone:
Home Work Cell
Birth Date:
SS Number:
Email:

Emergency Contact Person (Name, Phone Number and Relationship)

Parent/Guardian if under 18 (Name and Phone Number)
Education:
Degrees, Licenses, or Certificates Earned:
*Have you ever worked at The Hickman?       
Please make a selection.
HEALTH HISTORY
Health Condition: Excellent      Good     Fair      Poor

Any significant allergy, illness or disease you would like to make us aware of?

Any lifting or other health restrictions?
VOLUNTEER HISTORY AND INTERESTS

Any current or prior experience volunteering?

Special Skills/Interest/Hobbies:

Days you are available:
Mon.   Tues.   Wed.   Thurs.   Fri.   Sat.   Sun.

What time of day would you be available?
Day      Evenings     Weekends    

How many hours can you donate?    

Do you prefer:
1 to 1 interaction with residents      Group activities with residents

What kind of volunteer work are you most interested in?:
REFERENCES
Name Telephone Relationship Years Known
1)
2)
3)
OCCUPATION (List your current or last employer)
Company Dates
Address
Phone Job Title
  • I have not been convicted of a violent crime and was never dismissed from employment due to abuse of clients or residents.
  • I understand that this facility respects residents' rights with regard to privacy of information and I agree to respect these rights in the performance of my volunteer duties and keep "professional" confidentiality in all my statements outside The Hickman; and I agree to respect residents' rights to privacy, as well as those of the family and the facility when out in the community or socializing with others.
  • If selected to participate in The Hickman's volunteer program, I agree to abide by the established rules and regulations of the facility.
  • I understand that my volunteer relationship can be terminated at any time, at either the option of the facility or myself.
  • I voluntarily give The Hickman the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.
  • I certify that the above information in this application is correct to best of my knowledge.
You must agree to proceed. I understand and agree to the above statements.