1700 SW 7th Street, Topeka, Kansas 66606-1690      785-295-8000
St. Francis Health Center
 
 
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To apply for a volunteer position, please fill in the form below and click Submit. Once you have submitted your request, you will be able to print a copy to keep for your records.



Last name 
Middle Initial 
Legal first name 
Email Address 
Street Address 1 
Street Address 2 
City 
State 
Zip 
Home Phone 
Work Phone 
Cell Phone 
Date of birth 
Who to call in emergency 
Emergency Contact Phone 
Emergency Contact Relationship 
If spouse was listed as emergency contact, please also list below an emergency contact other than spoulse. 
Emergency Contact 2 Name 
Emergency Contact 2 Phone 
Emergency Contact 2 Relationship 
Do you have any conditions that would prevent you from performing the essential function of a volunteer position with or without reasonable accommodation? 
Work history (if no paid work history, put volunteer service history and specify that it was volunteer services) 
Most recent Employer 
Dates of service 
Phone # 
County or Address wtih zip code 
Position held and responsibilities 
Employer #2 
Dates of service 
Phone # 
County or address wtih zip code 
Position held and responsibilities 
Employer #3 
Dates of service 
Phone # 
County or address with zip code 
Position held and responsibilities 
May we contact the above companies for a reference? 


List name, address and telephone number of two (2) persons not related to applicant that we may contact for references. 
Name 
Address or Email 
City 
State 
Zip code 
Phone 
Name 
Address or Email 
City 
State 
Zip code 
Phone 
Have you ever been convicted or received a deferment for a crime? 
Note: You do not need to disclose minor traffic violations such as speeding or parking tickets. Reckless and/ro drunk driving is not a minor office and should be disclosed. 
If yes, when, where and what aws the nature of the offense? (Note: A conviction does not disqualify you from volunteer consideration). 
Is your name or a name you know to be referring to you on any local, state, or national registry, incuding but not limited to registries for sexual offenders? If so, please identify the registry: 
Have you been ordered by a judge to do community service as an alternative to a fine or jail sentence? 


If placed as a St. Francis volunteer, wll your volunteer hours be used for court-required community-service hours? 
How many of these court-required community service hours do you intend to provide to St. Francis, if placed as a volunteer? 
Do you have a parole officer 



If yes, please list name and number of parole officer 
Are you a citizen of the United States 


If not, do you have a green card or other valid authorization to reside in the United States (visa, permanent resident card, etc.) A copy will need to be provided if you are placed as a volunteer. 
Do you know anyone at St. Francis? 
If yes, who? 
Are you related to anyone working at St. Francis? 
If yes, wehre do they work? 
Has St. Francis ever employed you? 
If yes, when? 
Previous volunteer experience (when and where) 
What did you enjoy most? 
What did you enjoy the least? 
How did you hear about our volunteer program? 
Do you have a specific area in mind to volunteer? 
The typical commitment is a 4-hour shift, one shift per week ( usually 8-12: 12-4; 4-8). What day(s) and shift(s) are best for you? 
Any comments about yourself that you may wish to share? 
I understand that: 
1. Services as a volunteer are donated without expectation of compensation or future employment by St. Francis Health Center. 


2. Any benefits offered to volunteers may be changed or removed at any point in time. Volunteer services are rendered for humanitarian, religious, or other charitable reasons. 


3. Completion of this application process does not guarantee a volunteer assignment, nor am I bound to accept an assignment. 


4. I am granting permission for the references listed on the previous page and/or agencies to release information to the St. Francis Volunteer Services Department. It is understood that this permission includes cumulative and confidential information. 


5. St. Francis Health Center is a tobacco-free environment throughout its main campus and all of its affiliated sitesextending to campus grounds, including the parking garage and parking lots. 


6. As a part volunteer placement, volunteers are required to wear the official volunteer uniform as designated by the Volunteer Services Department and abide by the established dress code. 


7. Either St. Francis Health Center or I may terminate our volunteer relationship at any time, either with or without cause, and also with or without advanced notice. 


8. The facts set forth in my application for volunteer service are true and complete. 


9. False statements, answers or omissions on this application shall be sufficient cause for non-consideration for placement or for dismissal after volunteer placement.  
Signature (to be collected on site at hospital) 
Date 
 

Upon receipt of this application, you will be asked to sign a volunteer agreement, stating that you understand the conditions of submitting an application and the expectations of being a volunteer at St. Francis Health Center.