OSF St. Mary Medical Center - Volunteer Services

Volunteer Services Application Form

Personal Information:
Name (first, last, middle initial)
Date of birth
Phone (with area code)
Street address
City
State
Zip
Work History:
Are you employed? Yes No	Are you retired Yes No
If yes for employed, where?
How long have you been there?
Name and phone number of a person we can contact at that place of employment?
Other Information:
Have you ever pled guilty to or been convicted of any criminal offense other than minor traffic violations?	Yes No
If yes please explain.
Please List 3 references that are non-family members:
Name
Address
Phone

Name
Address
Phone

Name
Address
Phone
Your Preferences:
Position(s) you are interested in:
Gift Shop 9am-12pm 12pm-4pm 4pm-7pm
Information Desk 9am-12pm 12pm-3pm 3pm-6pm
Surgery Waiting Area 6am-?
Courier 9am-12pm 12pm-3pm
Patient Escort 6am-11am

What days are you free to work?
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday

Please click once to submit application