University Health Care System
(706) 722-9011

E-Mail Form

Volunteer Application Form

Thank you for your interest in volunteering at University Hospital! Please fill out this application form and we will get back with you as soon as possible.

PLEASE NOTE: By submitting this application, I hereby declare that all the below statements are true and correct to the best of my knowledge, and I hereby authorize University Hospital to make any inquiries to determine my ability for volunteer service, with the understanding that any misrepresentation I make will be just and due cause for non-acceptance or dismissal as a volunteer. If qualified for volunteer service, I agree to abide by the rules and regulations of University Hospital, the policies and procedures of the volunteer program and the department to which I am assigned, and I will respect the confidentiality of patient information at all times. I understand and agree that I will not be compensated for any volunteer service I perform for University Hospital.



* Indicates required information
Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Email Address 
Home Phone 
Date of Birth (Month and Date Only) *  (mm/dd/yyyy)
Under 18? If yes, what is your full date of birth?  (mm/dd/yyyy)
Business Address 
Business Phone 
Cell Phone 
Emergency Contact Name 
Emergency Contact Phone  
When are you able to volunteer? 
Best day of the week to volunteer? 
What area(s) are you interested in? 
Have you ever been convicted of a crime (other than minor traffic violations)? 
If "Yes", please explain. (Criminal background checks are done on all applicants) 
EDUCATION RECORD 
School/City 
Years Attended (from/to) 
Degrees Received 
List any occupational skills, special talents or hobbies. 
WORK/VOLUNTEER HISTORY (list present or most recent experience first) 
1. Employer/Volunteer Station 
Address 
Phone 
Description of your work 
Reason for leaving 
May we contact this employer/volunteer station? 
2. Employer/Volunteer Station 
Address 
Phone 
Description of your work 
Reason for leaving 
May we contact this employer/volunteer station? 
PERSONAL REFERENCES (Not relatives) 
1. Name 
Address 
Phone 
Relationship 
2. Name 
Address 
Phone 
Relationship 
Authentication * 

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AWARDS AND RECOGNITION

  
     
© 2014   University Health Care System
1350 Walton Way, Augusta, Georgia
(706) 722-9011