Mr. Mrs. Ms. Miss Home Phone:
Last Name: First Name:
Business Phone: Cell Phone:
Street: Apt. #
City: State:
Zip: EMail:
Emergency Contact: Relationship:
Contact Phone:  
Employment Status: Employed Retired Seeking Employment Student Homemaker
Current Place of Employment/School: Work Experience:
Education: (Last Grade Completed) 8 9 10 11 12 School Name:
Receiving school credit for volunteering: Yes No College Year: 1 2 3 4
College Name: Major:
Post-Graduate Degree:  
Other languages spoken: Volunteer Experiences:
Recreational Interests / Hobbies: Days and Times Available:
Assignment Preferred: Clerical Transporting Food Services Therapeutic Recreation
Your reasons for volunteering: How did you learn about our program?
Have you ever been convicted of a felony? Yes No  
If yes, give exact details of conviction, offenses, where committed, sentencing court, and the date and nature of the sentence:
References (non-family members)  
Name: Address:
Phone:  
Name: Address:
Phone:    
 

AFTER COMPLETING APPLICATION, PLEASE READ CAREFULLY AND MARK below.

1. I give permission to The Silvercrest Center of Nursing and Rehabilitation to investigate any and all concerning my application in order to determine my qualifications. This includes, but is not limited to medical clearance, criminal background checks, employment and personal reference checks. I understand that any misrepresentation of facts contained in this application may cause for my rejection or dismissal.

2. I agree to abide by the facility’s rules and regulations. I understand that if placed, my placement will be subject to the conditions of any applicable introductory period established by facility’s I understand that this application and any other medical center documents are not contracts of employment, and that any volunteer who is placed may voluntarily leave under proper notice, and be terminated by the facility at any time for any reason.

3. In the event of resignation or termination, I agree to return all Silvercrest’s property loaned to me, such as identification badge, keys, etc…..

4. I attest that my services to The Silvercrest Center for Nursing and Rehabilitation is being given without contemplation of compensation or future employment.

Checking "Accept" below indicates that I have read, understood and contested to the above statements. This authorization or photocopy thereof shall serve as consent for Silvercrest to request information concerning my application.
  I Accept
 
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