Volunteer application form

Print, and mail comleted form to:

New Jersey WAVE

c/o Voorhees Pediatric Facility

Attention: Tricia Cunningham

1304 Laurel Oak Road

Voorhees, NJ 08034-4392



Name: Last, First,Middle						Social Security Number


Mailing Address


City				State			Zip Code

( )			( )			( )
Home Phone			Work Phone/ Other			Other


E Mail Address

Emergency Contact Person:

					( )
Name						Phone


Address

Please indicate position(s) you are interested in /qualified for:

	Activities				Occupational Therapist
	Physician				Physical Therapist
	Nurse				Physical Therapist Aide
	CNA				Recreational Therapist
	Respiratory Therapist				Speech Therapist
					Other:
						Please specify




List and explain any limitations that may impede performing an essential element of the selected
position(s).









Education


High School				Years completed


College/University				Years completed			Degree


College/University				Years completed			Degree

License / Certification


Professional License					License Number		Expiration Date


Certifications (CPR,PALS,ACLS,CCRN, CNP etc.)					Expiration Dates


Certifications (CPR,PALS,ACLS,CCRN, CNP etc.)					Expiration Dates


Certifications (CPR,PALS,ACLS,CCRN, CNP etc.)					Expiration Dates

Employment History
List positions including volunteer, starting from most recent.


Name of Employer				Address			Phone Number


Position Held				Date From/To			Reason for Leaving


Name of Employer				Address			Phone Number


Position Held				Date From/To			Reason for Leaving


Name of Employer				Address			Phone Number


Position Held				Date From/To			Reason for Leaving





References
(At least two professional references)


Name					Phone Number


Relationship					Years Known


Name					Phone Number


Relationship					Years Known


Name					Phone Number


Relationship					Years Known


Skills

Please list any skills / education that would be helpful during the excursion. (sports,music, crafts etc)





The information in this application is correct to the best of my knowledge, and I understand that
NJ WAVE will not be liable for any untrue or omitted information.


Signature							Date

All documents will become part of future volunteer personnel files for NJ WAVE.


Please return your completed application, a copy of your professional license, and any
certifications to:

		NJ WAVE
		C/O Voorhees Pediatric Facility
		Attention: Tricia Cunningham
		1304 Laurel Oak Road
		Voorhees NJ 08054