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Cooley Dickinson Health Care Volunteer Application Form

Thank you for your interest in Volunteering at Cooley Dickinson Hospital. We look forward to having you join us in providing outstanding care to our patients and their families.

To help us best utilize your time and skills, please complete the application form and return it to Volunteer Services. You must be at least 15 years old to apply. Once your application has been received we will contact you to arrange an interview.

The process for becoming a volunteer may take a few weeks. To protect you as well as patients, the following will need to be completed:

  • Criminal Records check (CORI) form (completed at interview)
  • TB screening
  • A copy of your immunizations [mumps, rubella (German measles), rubeola (measles), chickenpox and hepatitis B, if applicable]
  • Two letters of reference
  • Orientation (held monthly and scheduled after TB screening has been completed)

We request a minimum commitment of 60 hours over 6 months. Exceptions may be made for students or with the permission of the department.

Robin Kline
Director of Volunteer Services

APPLICATION

Please fill out the form below completely and then click the “submit” button to submit your volunteer application. It is the intent of CDHC to conform to Federal and State Laws pertaining to non-discrimination.

Mr.Mrs.MissMs.

First Name

Middle Name

Last Name

Street Adress

City

State

Zip

Home Phone

Business/Cell Phone

Email address

Confirm email address

In case of emergency notify:

Name

Address

Phone

Relationship

VOLUNTEER GOALS & EXPERIENCE

What do you hope to gain from your volunteer experience?

What is your current occupation?

Please describe any prior or current volunteer or community activities:

Please list any skills, hobbies or interests which will help us place you appropriately:

Have you ever volunteered at CDH before? (If yes, when?)
YesNo

Were you ever employed by CDHC?
YesNo

Are you a member of the Friends of Cooley Dickinson (formerly the CDH Auxiliary)?
YesNo

Are you a member of RSVP?
YesNo

Would you be interested in joining the Patient Family Advisory Council?
YesNo

Please indicate the best days and times to volunteer:

Monday
8 am-12 pm12 pm-4 pm4 pm-8 pm

Tuesday
8 am-12 pm12 pm-4 pm4 pm-8 pm

Wednesday
8 am-12 pm12 pm-4 pm4 pm-8 pm

Thursday
8 am-12 pm12 pm-4 pm4 pm-8 pm

Friday
8 am-12 pm12 pm-4 pm4 pm-8 pm

Saturday
8 am-12 pm12 pm-4 pm4 pm-8 pm

Sunday
8 am-12 pm12 pm-4 pm4 pm-8 pm

STUDENTS ONLY

School:

Major:

Is this an Internship for credit?
YesNo

How many total hours are required?

Commitment Level:
Entire School YearFall Semester OnlySpring Semester OnlySummer Only

Year in School:
FreshmanSophomoreJuniorSenior

Are you at least 15 years of age?
YesNo

REFERENCES (Do not include relatives)

1 | Name

Address

Business/Occupation

2 | Name

Address

Business/Occupation

3 | Name

Address

Business/Occupation

EMPLOYMENT HISTORY

1 | Name

Address

Phone

Position/Duties

Dates Employed
From

To

2 | Name

Address

Phone

Position/Duties

Dates Employed
From

To

3 | Name

Address

Phone

Position/Duties

Dates Employed
From

To

EDUCATION

High School

Course of Study

Graduated?
YesNo

College/University

Course of Study

Graduated?
YesNo

Other Schools

Course of Study

Graduated?
YesNo

Have you ever been sanctioned or excluded or been the subject of a sanction or exclusion proceding by Medicare, Medicaid or other federal health care program?
YesNo

Please Read Carefully

By clicking "I accept," I attest that all of the above statements are true to the best of my knowledge. I understand that any misstatements are sufficient cause for my dismissal. I authorize the Cooley Dickinson Health Care Corporation to verify any information presented in this form and to request statements from references. In the event of my volunteering for the Cooley Dickinson Health Care Corporation, I agree to comply with all of the Cooley Dickinson Health Care Corporation’s rules and regulations as they may be changed from time to time.

I ACCEPT

Today's Date:

 If you would prefer to download, print and mail your application, please click HERE for a downloadable PDF and mail to:

Cooley Dickinson Hospital
30 Locust Street
P.O. Box 5001
Northampton, MA 01061
Volunteer Services