FCCC Adult Volunteer Application

* First name

M.I.

* Family/Last name

Preferred Nickname

Gender

Title

* Address

* City

* State

* Zip/postal

Work phone

Home phone

* Mobile phone

* E-mail

Consent to receive reminders and updates via text message (contact us at any time to change your preference)

Are you applying to provide Reiki services?

Do you plan to volunteer with a pet (certified animal)?

* Pet Name

Emergency Contact Information

* Contact name

* Relationship

Address

City

State

Zip/Postal

Home phone

Mobile phone

Work phone

E-mail (if applicable)

Additional Information

Volunteer source

How long can you commit to volunteering?

Primary Language

Please list any additional languages

Uniform Size

Skills

What type of assignment(s) interest(s) you?

If any, please indicate other interests

I have been accepted into a Lab or Program at FCCC

If you have an assignment, please do not complete this form. Contact VolunteerServices@fccc.edu for information.

I am a student

Please use our college student application if you are currently enrolled as a student in a college or university (including graduate students and medical students)

I am employed

I am employed by a Temple University Health System entity (Fox Chase Center Center, TUH, etc.)

* TUID

Employer

Occupation

Street Address

City

State

Zip/Postal

I am retired/unemployed

Availability

Monday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Tuesday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Wednesday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Thursday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

Friday

7 am to 9 am

9 am to 2 pm

1 pm to 5 pm

Unavailable

References

Please list two people (other than relatives or friends) who would be willing to serve as personal references.

Reference 1

* Name

* E-mail

Reference 2

Relationship to Reference 2 (cannot be a relative)

* Name

* E-mail

Attestation of Application Answers and Information Provided

I understand that the statements made in my volunteer application are true and correct and have been given voluntarily. I understand that falsification of any information is grounds for dismissal. I voluntarily give TUHS/FCCC the right to make an inquiry of my past experience and I agree to cooperate in such inquiries and release from all liability or responsibility all persons, companies, and corporations supplying such information. I voluntarily give TUHS/FCCC permissoion to contact my references provided above. I understand that I will not be compensated for my services as a volunteer and I am not required to volunteer my services. I understand that acceptance as a volunteer at TUHS/FCCC is contingent upon satisfactory completion of all pre-placement procedures which include but are not limited to orientation, an interview, criminal background investigation(s), completion of HIPAA Certification and completion of required health screenings. I understand that upon my successful completion of the volunteer service on-boarding processes required at TUHS/FCCC and the approval for placement by volunteer Services staff, I will become a volunteer. I agree to abide to the policies of TUHS/FCCC and if I do not, this may result in disciplinary actions. I am aware of and will honor the schedule commitment I make during my interview with Fox Chase Cancer Center Volunteer Services.

* I have read the statement above and I understand and agree.

* Name

* Date

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Signature