Volunteer Form - Brooks Rehabilitation

Personal Info

Full Legal Name*

Date of Birth*

Home Address*

City*

State*

Zip*

Contact Phone Number*

E-mail Address*

Leisure Time/Hobbies Interest*

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone*

Current Job Title, Volunteer Assignment or Grade Level*

Current Employer, Volunteer Location or School*

Skills That Apply to You*

Office Skills
Arts/Crafts
Gardening
Medical
Retail
Other

Other*

Volunteer Assignment

Why are you interested in volunteering at Brooks?*

How did you learn about volunteer services at brooks?*

When are you available to volunteer

Hours:*

AM
PM
Both
Specific Hours

Specific Hours

Days:*

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Where are you interested in volunteering? Please check any that apply.*

Brooks Rehabilitation Hospital
Outpatient Clinic
Brooks Clubhouse
Bartram Crossing (Skilled Nursing)
Bartram Lakes (Assisted Living)
Brooks Greenhouse (Memory Care)
Other Location

Other Location*

References and Other Information

Please list two people (other than a relative) who can provide a reference. (i.e. former employer, church affiliate, business associate, school counselor)

Name*

Best Way To Contact*

How Do You Know Them?*

Name*

Best Way To Contact*

How Do You Know Them?*

Do you know a volunteer(s) at Brooks Rehabilitation*

Yes
No

If Yes, Who*

Have you ever been convicted of a felony?*

Yes
No

If Yes, Please Explain*

Consent*

By checking this box I agree to the following –

I hereby apply for volunteer services at Brooks Rehabilitation and agree to abide by the policies and regulations governing this organization. I also give permission to Brooks Rehabilitation to conduct necessary background checks as required for volunteers. I understand that the hours I serve as a volunteer are without promise, expectation, or receipt of compensation for service rendered. I also further understand that I will not expect to be hired for a paid position in the future, solely based on the fact that I was a volunteer for Brooks.

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