Beth Israel Deaconess-Plymouth

Pastoral Application

* First name

Middle name

* Last name

* Street Address:

Mailing Address if Different from Street Address:

* City

State

* Zip

* Phone

* E-mail

* Date of Birth

Have you ever been a volunteer before?

If Yes: where?

If you work or have worked in the past please list the type of work you do/did:

References

We request that you provide us with three (3) references who can be either a friend (over 22 years of age), clergy member, former employer, teacher, etc. (not a relative). Please include their name, relationship,telephone number and e-mail address so that we may contact them.

* Name

* Relationship

* Telephone #

* Email address

* Name

* Relationship

* Telephone #

* Email Address

* Name

* Relationship

* Telephone #

* Email Address

I give permission for Beth Israel Deaconess Hospital-Plymouth Volunteer Services to contact and obtain a personal reference from the people I have listed above.

Emergency Contact

* Emergency contact's name

* Relationship

* Phone

Physician

* Physician's name

* Phone

Schedule

Beth Israel Deaconess Plymouth's Catholic Chaplain will discuss scheduling with applicant.

*PLEASE NOTE ALL VOLUNTEERS ARE REQUIRED TO HAVE THEIR MMR, TB/MANTOUX, VARICELLA, FLU IN SEASON, THE ORIGINAL COVID SERIES PLUS ONE BOOSTER OR THE COVID BIVALENT VACCINE. This is provided free of charge by our Occupational Health department. You will be directed to Occ. Health after the interview process.

Excessive unplanned absences, improper dress or manner or any disregard for hospital or departmental policies and procedures will be grounds for immediate termination of volunteer assignment.

* Signature: (Typed name accepted as Electronic Signature)

* Date: