Giving & Volunteering

Volunteering: Teen Program

Name:
Date of Birth:
Address:
City, State, ZIP:
Home Phone:
Work Phone:
Email Address:
Best day(s) and time(s) to contact you:
 
Emergency Contact Name:
Emergency Contact Phone:
EDUCATION
Highest Grade Level Completed:
 
Grammar
High School
College
Degree Attained:
Degree Attained From:
Are you presently enrolled as a student:
 
Yes
No
Name of School:
Degree you will recieve and date:
 
EMPLOYMENT HISTORY
Are you presently employed:
 
Yes
No
Are you retired:
Yes
No
Current Employer:
Position:
Phone:
Length of Employment:
Past Employer:
Position:
Phone:
Length of Employment:
VOLUNTEER EXPERIENCE AND TRAINING
(If you have volunteered at another organization)
Organization #1:
When:
How Long:
Your Duties:
Organization #2:
When:
How Long:
Your Duties:
Organization #3:
When:
How Long:
Your Duties:
REFERENCES
(Please provide complete addresses for all references listed)
Reference #1 Name:
Phone:
Relationship:
Address:
City, State, ZIP:
Reference #2 Name:
Phone:
Relationship:
Address:
City, State, ZIP:
References #3 Name:
Phone:
Relationship:
Address:
City, State, ZIP:
BACKGROUND INFORMATION
(Please answer the questions below as completely as possible.)
Do you have any physcial disabilities that may affect or limit your work:
 
Yes
No
If yes, please describe:
Are you on any medication(s) and/or under medical supervision:
 
Yes
No
If yes, please describe:
Have you ever been convicted of a felony:
 
Yes
No
If yes, please describe:
GENERAL QUESTIONS
How did you hear about our employment opportunities:
 
What interests you in employment with us:
 
What foreign language do you speak fluently:
 
CERTIFICATION OF APPLICANT
By submitting this form, you certify that your answers on this application are true and complete to the best of your knowledge. You also grant your permission and consent for us to contact the necessary resources and references to verify your responses on this application.
 
 

Madonna Rehabilitation Hospital
5401 South St. • Lincoln, NE 68506
Phone: (402) 489-7102 • Toll-Free: (800) 676-5448
E-mail: info@madonna.org
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