Phoebe Ministries - Volunteer Application - Phoebe Berks Health Care Center

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Volunteer Application
Phoebe Berks Health Care Center

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Work Phone:

Home Phone:

May we contact you at work? Yes No

Birthday: / / (mm/dd/yyyy)

Are you presently employed? Yes No

If yes, how many hours per week?

Previous work experience:

Interest skills and hobbies:

Church affiliations/clubs/organizations:

Times prefered for volunteer work:
Day(s) of week: AM PM

Are you physically able to transport wheelchairs? Yes No

Do you have any medical
restrictions that would limit your activity? Yes No

In case of emergency, notify:

Relationship:
Phone:

Physician:
Phone:

Name and address of two personal references:

1.
Phone:

2.
Phone:

Interests

activities bus driver

Do you have a current valid Pennsylvania Driver’s license/CDL license?	Yes No
Do you have any previous experience working/volunteering as a driver?	Yes No
If yes, what types of vehicles did you drive previously?	Yes No

activities helper
arts and crafts
assistance to the blind/menu assistant
Auxiliary member
bird care
Bridgeways (Alzheimer's Unit) helper
cooking group leader
current events/discussion groups
exercise class
friendly visitor/TLC visitor/one-to-one sensory stimulation
gardening activities/intergenerational activities
gift shop
holiday parties, special events
in-house wheelchair transportation for activities and/or appointments
letter writing
lobby receptionist/clerical assistant/business
office helper
meal companion for feeding
men's group activities
musical entertainment (Do you sing or play an instrument?
outdoor walks
outside appointment escort (staff driver and vehicle)
pet visits
shoppers helper - community malls/stores
spiritual activities/worship service monitor (Sunday)
table games/cards
trip escort (restaurant, seasonal bus ride)
water/ice - nursing unit helper
other

I (name of prospective volunteer) understand that any misrepresentation or omission of information on this application may disqualify me from being a volunteer.

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