First Name: *				Last Name: *
		Address:				City:
		State:				Zip:
		Phone: *				Email: *
		Marital Status:		Single Widow Married Separated Divorced		Spouse:
		Birth Date:
		Occupation:				Employer:
		Employer Phone:

		Relative Name:				Relationship:
		Home Phone:				Work Phone:

		Are you currently in school?				Yes   No
		If yes, please list the school you are attending:

		Name:				Phone:

		Volunteer Experience:
		Education / Special Training:
		Hobbies / Special Interests:
		List Physical or Mental Limitations:
		Community Affiliations & Offices Held:

		Speak:				Write:
		Read:

		Have you ever been convicted of a felony?				Yes   No
		If yes, list dates and circumstances:

		Have you ever worked or volunteered for this hospital before?				Yes   No
		Have you ever volunteered at a hospital before?				Yes   No
		If so, please list where and what your volunteer duties included:
		How did you decide to volunteer at Phoenix Baptist Hospital?

References: Please give the name of 2 people NOT RELATED TO YOU that have known you for at least one year.

		Name:				Phone:
		Years Acquainted:				Business:
		Address:
		How does this person know you?

		Name:				Phone:
		Years Acquainted:				Business:
		Address:
		How does this person know you?

PLEASE INDICATE TIMES AVAILABLE TO VOLUNTEER
(Shifts generally run 8 am to 12 pm, 12-4 pm, 4-8 pm)

		Monday:		8am to 12pm 12pm - 4pm 4pm - 8pm		Tuesday:		8am to 12pm 12pm - 4pm 4pm - 8pm
		Wednesday:		8am to 12pm 12pm - 4pm 4pm - 8pm		Thursday:		8am to 12pm 12pm - 4pm 4pm - 8pm
		Friday:		8am to 12pm 12pm - 4pm 4pm - 8pm		Saturday:		8am to 12pm 12pm - 4pm 4pm - 8pm
		Sunday:		8am to 12pm 12pm - 4pm 4pm - 8pm
		Other:

		Patient, Family & Public Contact areas: Admitting Dietary Services Diagnostic Imaging Emergency Room Family Medicine Center Gift Shop Information Desks Medical Clinics Nursing Units People Moving Cart Post-Anesthesia Care Recovery Room Respiratory Therapy Surgery Department Waiting Areas Wellness Connection Women's/Birthing Center				Non-Patient Contact Areas: Administration Business Office Education Employee Health Finance Department Health Records Human Resources Lab Marketing Pharmacy Physician Services Volunteer Services Office