Junior Volunteer | Idaho Falls Community Hospital

Reference 1

Name

Relationship

Phone

Reference 2

Name

Relationship

phone

Time Available

Have you ever been accused, disciplined, found guilty or convicted of any type of harassment, violence or infraction involving dishonesty or financial impropriety in the work place? *

Yes
No

If YES, explain

Have you ever been convicted or entered into a plea bargain for a crime? *

Yes
No

If YES, explain

Are there any work activities or conditions you must avoid?

Activity Level

High (Able to walk long distances-walk frequently-pushing wheelchairs-stairs-lifting)
Moderate (Able to walk short distances and in spurts-light lifting)
Light (Mostly sitting with limited walking)

Reference Checks

Yes
No

By signing below you are confirming that the above information is true to the best of your knowledge.

Signature

Date