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Volunteer Services Application Form

First Name: *

Last Name: *

Address: *

City: *

State: *

ZIP Code: *

Home Phone: * xxx-xxx-xxxx

Cell Phone: xxx-xxx-xxxx

Work Phone: xxx-xxx-xxxx

Email: *

Emergency Contact Name:

Phone: xxx-xxx-xxxx

Work or Volunteer Experience

Current Occupation:

Employer (If Applicable):

Description:

Reference/Relationship:

Phone: xxx-xxx-xxxx

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Were you refered by Rush-Copley Volunteer?

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What days are you available to volunteer? *
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Mornings
Afternoons
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Comments regarding your availabilty:

Type of Service that interests you?

Public Contact (Info Desk, Waiting Areas, Shuttle)
Patient Contact (Flower, Paper, Coffee Delivery)
Clerical Support (Filing, Sorting, Copying, Phone)
Gift Shop (Sales, Stocking, Inventory, Display)
Fund Raising (Project Support)
Spiritual Care (Support Patients, Families and Guests)
Special Projects (On Call for Miscellaneous Support)
Other (Describe)

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Rush-Copley Medical Center • 2000 Ogden Avenue; Aurora, IL 60504 • 866-4COPLEY (1-866-426-7539)

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