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Volunteer Application

Volunteers Services Department Application

Via Christi Hospital, 929 N. St. Francis 316-268-5172 Fax: 291-7785
Via Christi Hospital, 3600 E. Harry, 316-689-6079 Fax: 691-6704
Via Christi Hospital, 14800 W. St. Teresa, 316-689-6079 Fax: 691-6704
Via Christi Rehab Hospital 1151 N Rock Road 316-634-3601 Fax: 634-1141

The selection and placement of volunteers will be made without discrimination on the basis of race, color, religion, sex, age, national origin, or disability or any other protected classification. Via Christi Volunteer Services does not accept applications for court-ordered service. Please fill out the following form and click the "Submit" button at the bottom.
* Indicates required information
I am interested in volunteering at the following location: * 




Date of Birth * 
Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Email Address * 
Home Phone * 
Business Phone 
Cell Phone 
 
Character References 
(three adults, not relatives, you have known for at least 2 years.)  
(1) Name * 
(1) Title * 
(1) Relationship * 
(1) Street Address * 
(1) City * 
(1) State * 
(1) Zip * 
(1) Phone Number * 
(1) Email Address 
(2) Name * 
(2) Title * 
(2) Relationship * 
(2) Street Address * 
(2) City * 
(2) State * 
(2) Zip * 
(2) Phone Number * 
(2) Email Address 
(3) Name * 
(3) Title * 
(3) Relationship * 
(3) Street Address * 
(3) City * 
(3) State * 
(3) Zip * 
(3) Phone Number * 
(3) Email Address 
 
Employment  
I am * 
Employer (or School) 
Occupation 
Have you been employed at Via Christi? * 
If Yes, when? 
Position 
The name and relationship of relatives or friends currently employed by or volunteering at Via Christi: 
Relatives/Friends: 
 
Skills/Special Interests 
Education 
Degree 
Major 
 
Placement and Scheduling 
Date you are able to begin volunteering    (mm/dd/yyyy)
We ask volunteers to commit to a regular schedule. 
Number of hours/week you are available to volunteer 
Are you applying to fulfill a court-ordered community service?: * 
Are you applying to fulfill a school requirement?: * 
 
Criminal History (Do not include misdemeanor or traffic violations) 
Have you ever been convicted for violation of any federal, state, county or municipal law, regulation or ordinance?: 
Convicted?: * 
(Note: A criminal background check will be performed on all adult applicants.) 
Acceptance: * 

 

 

  
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