NURSE FORMS

THIS HAS BEEN PAUSED FOR 2023-2024

INTERESTED IN BECOMING a Community Health/Nurse Volunteer?

APPLY BY completing

THE FOLLOWING FORMS

APPLY TO BE A COMMUNITY HEALTH NURSE/VOLUNTEER

(Must follow all steps)

SCHEDULE AN INTERVIEW

RN Interview Request

Name

First Name

Last Name

Availability?

Which day of the week is best for you:

Monday

Tuesday

Wednesday

Time of Day?

Is there a time the works best for you:

morning

afternoon

Any questions or comments?

Volunteer Position

What position are you interviewing for?

Registered Nurse

I'm still deciding

Thank you for your interest! We will be in contact soon.

2. FILL OUT THESE FORMS

a.

Community Health Nurse Volunteer

Today's Date

YYYY

Name (first, middle, last)

Cell Phone

(###)

###

####

Daytime Phone

(###)

###

####

Home Phone

(###)

###

####

Current Address

Email Address

If you have lived at your current address less than seven years, provide information on all addresses during that period. (Needed for Criminal History Check)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

List all other names by which you have ever been known.

Birth Date

YYYY

Social Security #

PLEASE NOTE WE NEED THIS INFORMATION TO COMPLETE YOUR BACKGROUND CHECK. WE WILL NOT SHARE THIS INFORMATION.

Drivers License #

RN NSQ Lisence#

Length of membership/attendance at CA

Are you 18 years of age or older?

T-shirt size?

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Relationship

References

List at least two references from places of employment or prior volunteer service, especially concerning previous work with youth. References must meet the following criteria: must be over age 18; must not be a relative; must have known you for at least one year.

Reference #1 Name

First Name

Last Name

Reference #1 Email

Reference #1 Phone

(###)

###

####

How long have you known this person, and how did you meet?

Reference #2 Name

First Name

Last Name

Reference #2 Email

Reference #2 Phone

(###)

###

####

How long have you known this person, and how did you meet?

Please indicate for what role you would like to volunteer:

Weekly Volunteer Options

Please indicate the days and times you are available to give one hour:

Please list previous volunteer activities:

Volunteer Pledge

If I am assigned as a school volunteer, I accept the responsibility to serve in support of the educational program and supplement the work of the professional staff, under their guidance. I understand that it is important to be reliable, channel suggestions constructively, keep information confidential, and comply with school rules. As a member or regular attendee of this church, I agree to be accountable to the leadership of this church regarding my Christian life and witness according to the biblical witness of this Church and in all aspects of conduct and performance related to this volunteer position. I hereby represent and warrant that the information contained in this application is correct and complete to the best of my knowledge. I authorize any references, or any other person or organization, whether or not identified in this application, to give you any information (including opinions) regarding my character and fitness for volunteer service. I understand that a very positive benefit, when working with students, is the relationship developed between the volunteer and student. I take seriously the relationship that will be formed. I agree to a criminal history check (national and/or state level). My initials on this form authorizes you to make such checks and to disclose results to both Church and School personnel as part of the KIDS HOPE USA program. By pressing “submit” on this form I am agreeing to these terms and I am agreeing that the information is provided by the applicant on this form.

Agree

INITALS

Signature

please sign in-person on day 1

Today'd Date

YYYY

b.

CODE OF CONDUCT

3. TB TEST FORM

Schedule an appointment with your medical provider or local clinic.

Have the physician complete the TB Clearance Form, THEN scan and email it to crystald@cachurch.com

c.

TB TEST FORM

THIS HAS BEEN PAUSED FOR 2023-2024

INTERESTED IN BECOMING a Community Health/Nurse Volunteer?

APPLY BY completing

THE FOLLOWING FORMS

APPLY TO BE A COMMUNITY HEALTH NURSE/VOLUNTEER

(Must follow all steps)

SCHEDULE AN INTERVIEW

2. FILL OUT THESE FORMS

a.

b.

3. TB TEST FORM

Schedule an appointment with your medical provider or local clinic.

Have the physician complete the TB Clearance Form, THEN scan and email it to crystald@cachurch.com

c.