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Adult Volunteer Application

Last Name: *	First Name: *	MI:
Facility: The Reading Hospital and Medical Center/The Reading Hospital for Post-AcuteRehabilitation.
Required fields are indicated with (* )
Personal Information

Address: *

City: *	State: *	Zip: *

Home Phone: *	Cell Phone:	Work Phone:

Email: *

Please use a reliable email address. Correspondence will be sent to you via email frequently.

Date of Birth: * / /

First Name: *	Last Name: *	Relationship: *
Emergency Contact Information

Same as Applicant
Address: *

City: *	State: *	Zip: *

Home Phone: *	Work Phone:	Cell Phone:

Optional Census Information
Gender: Male Female
Ethnic Origin:
American Indian or Alaska Native Asian Black/African American Hispanic	Middle Eastern Native Hawaiian or Pacific Islander White/Caucasian
Education:
Education level: * High School College Graduate

Work History:
Work Status: * Employed Unemployed Retired

Criminal History
Have you ever been convicted of a crime other than a minor traffic violation?* No Yes
Explain in detail.

Question Section:
How did you hear about our program?
Friend	Brochure	Volunteer	TRHMC Web Site
Other (please specify)
What is you interest in volunteering at The Reading Hospital?
What skills do you have that you would like to share as a volunteer? Example: Clerical, computer, languages, interpersonal, etc

Volunteer Availability *
Select All:
Monday	Morning	Afternoon	Evening
Tuesday	Morning	Afternoon	Evening
Wednesday	Morning	Afternoon	Evening
Thursday	Morning	Afternoon	Evening
Friday	Morning	Afternoon	Evening
Saturday	Morning	Afternoon	Evening
Sunday	Morning	Afternoon	Evening
Volunteer Program Requirements
I have read the requirements of becoming a volunteer at The Reading Hospital and Medical Center listed on the volunteer section of the Hospital’s website (Click here). These requirements include submitting an application and two letters of recommendation, completing a two step TB test, submitting an immunization record to Employee Health Services, completing a PA Criminal History check, completing a Child Abuse Clearance and FBI Fingerprint (if necessary), attending a volunteer orientation, obtaining a volunteer ID, and purchasing a uniform.
I Agree *

Reading Hospital: 484-628-8000

Patient Information: 484-628-8201

HelpLine: 484-628-HELP

Toll Free: 866-988-4377

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Mailing address: PO Box 16052, Reading, PA 19612-6052 | Email: info@readinghospital.org

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