Kaiser Permanente Medical Center

Volunteer Application – San Francisco 4131 Geary Blvd. #305 San Francisco, CA 94118 Phone: 415-833-2788 Email: [email protected] Personal Data

Address: City/Zip:

E-mail Address: Phone:

Presently Employed? No  Yes  If yes, where? Have you ever been employed by Kaiser  Yes If yes, name of facility When: Permanente or any other Kaiser Organization?  No or organization: Where: Position Held: Name Used:

Volunteer Type:  High School Student (age 16 & 17)  Adult (age 18 and over)

Volunteer / Work / Educational Experience

Volunteer Experience:

Work Experience:

Why are you seeking to volunteer?  Personal commitment  School Program  Other: ______

Please explain:

Are you currently attending school? No Yes If so, where?

Level of Education Completed: Field of Study:

Skills & Attributes

Please indicate below the attributes and skills that you possess:

Customer Service Creative Technical Positive Attitude Musical Instrument Computer Skills Initiative/Proactive Drawing/Painting Telephone Listening Skills Humor/Storytelling Office Machines Patience Singing Reception Desk Skills Understanding/Empathy Sewing/Needlework/Crafts Typing Please describe any other attributes/skills/special trainings:

Please share your hobbies/ special interest/ extracurricular activities:

Language Proficiency (other than English):

Service & Availability

How did you learn about the Volunteer Program?

Do you have a preference for service area?  No  Yes

If yes, please list your top three choices: 1) 2) 3)

Can you commit to volunteering for a minimum of one year? No  Yes 

Do you have any limitations you would like us to know about?

Please indicate the time of day and days of the week you are available to volunteer. Shifts may include: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Mornings

Afternoons

Evenings

 Applicant Statement

 I certify that all answers in this volunteer application are true and correct and have been given voluntarily  I understand that completing an application does not guarantee acceptance into the Volunteer Program  I understand that the position of Volunteer requires that I be available to volunteer for a minimum of 1 year  I understand that incomplete applications will not be considered  I understand that volunteering may not lead to employment

Signature ______Today’s date ______

Parental/Guardian Signature: (under the age of 18 years old)

My child, (insert name) ______has my consent to participate in the Kaiser Permanente San Francisco Volunteer Services Program should he/she be selected as a Volunteer. I assume all responsibility for his/her service in this program to be in accordance with the policies, procedures, and expectations of Kaiser Permanente volunteers. I have reviewed the description of the program. My child may participate in all activities in connection with his/her assigned duties, with or without accommodation. In the event I cannot be contacted, I hereby give permission for Kaiser Permanente to administer emergency health care to my child.

Parent/Guardian Signature ______Today’s date ______