Volunteer Online Form

Thank you for your interest in volunteering with Jacksonville Speech & Hearing Center. You will have opportunities to gain work and life experiences, meet new people, strengthen leadership skills, and make a difference in someone’s life.

GENERAL INFORMATION:

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone Number

Occupation

Former or Current Employer

Emergency Contact: Name

Emergency Contact: Phone #

Address

Relationship

Type of Volunteer

Teen
College Student
Adult

If enrolled in school: Name of School:

Grade Level:

Volunteer

How did you learn about volunteer opportunities with Jacksonville Speech & Hearing Center?

Reason(s) for applying with Jacksonville Speech & Hearing Center as a volunteer:

Type of Volunteer Activity Desired:

(Check all that apply)

Administrative/Clerical
Special Events
Health/Community Fairs
Hearing Screenings
Assisting Speech Therapists
Assisting Audiologists
Development/Marketing
Internship
Wherever needed most

What days & times can you volunteer? (Include weekends & evenings)

Previous or Current community service/clubs

Please use this space for any additional information you would like to provide or any comments you would like to make:

Have you ever been CONVICTED of an offense against criminal or military law, or are there criminal charges currently pending against you? (Exclude minor traffic violations)

Yes
No

If “Yes”, please give a detailed explanation about the nature of conviction and time since release from custody or probation?

I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that any misstatement of fact may result in termination. All statements made on this application, including employment information, are subject to verification as a condition of volunteer services. I hereby give permission for you to verify any information included in this application. I further understand that as a volunteer I may be exposed to some degree of confidentiality of working in this population of clients and agree to safeguard this information. I also understand that the hours I serve as a volunteer for JSHC 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 JSHC. I understand this volunteer opportunity is not a binding contract. Please list two people (other than a relative) who can provide a reference.

Name

Phone:

Address:

Name

Phone:

Address:

Do you know a volunteer(s) at JSHC?

Yes
No

If yes, please list their name(s):

Is there any medical condition JSHC should be aware of in determining your volunteer assignment(s)?

Yes
No

If yes, please provide details as your needs:

I hereby apply for volunteer services at Jacksonville Speech & Hearing Center (JSHC) and agree to abide by the policies and regulations governing this organization. I also give permission to JSHC to conduct necessary background checks as required for volunteers.

Signature of Volunteer:

Date