Ronald McDonald House of Southwest Virginia
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Family Room Volunteer Application
Family Room Volunteer Application
This application is to volunteer at the Ronald McDonald Family Room (located inside Carilion Children's Hospital)
*
I understand! This is where I want to volunteer
Oops! I meant to apply to be a Ronald McDonald House Volunteer instead
If you meant to apply to volunteer at the Ronald McDonald House, go back to the last page and select "Sign Up" under House Volunteer.
Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
Gender
Male
Female
Other
Do Not Wish To Disclose
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Personal Phone
*
Email
*
Preferred Method of Contact
*
Phone Call
Text
Email
How would you prefer that we contact you in response to your application?
How did you find out about Ronald McDonald Family Room?
Occupation?
Current Employer
Employer Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
May We Contact Your Employer?
Yes
No
Work Phone
May We Contact You At Work?
Yes
No
Reference #1
First
Last
Phone
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Reference #2
First
Last
Phone
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please describe what you consider an ideal volunteer job for you at this time (position, expectations, etc.) Why?
*
Special skills, training, and interests you would be willing to share in your work:
*
Please list previous volunteer experience. Include the organization, activities performed, and dates volunteered.
*
Preferred Days of the Week:
I'm flexible- whenever you need me the most!
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Time of Day
I'm flexible- whenever you need me the most!
9:00 am - 12:00 noon
12:00 noon - 3:00pm
3:00pm - 6:00pm
6:00pm - 9:00pm
Is it necessary to limit your physical activity in any way?
Yes
No
If yes, please explain.
Emergency Contact Information
First
Last
Relationship
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Work Phone
Carilion Clinic Childrens Hospital requires that you complete their volunteer orientation as well as have a TB test, drug screening, criminal background check, and a flu shot. Are you willing to complete these requirements?
*
Yes
No
Ronald McDonald House Volunteer Application Form
Thank You