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Membership Application
Kona Community Hospital Auxiliary
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* Indicates required question
Email
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Your email
First Name
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Your answer
Last Name
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Your answer
Address (Hawaii)
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Your answer
Other Address
Your answer
Cell Phone
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Your answer
Alternative Phone
Your answer
Preferred Method of Contact
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Email
Cell Phone
Mail
Required
Are you 18 years or older?
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Yes
No
Emergency Contact Name
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Your answer
Emergency Contact Phone Number
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Your answer
Occupation
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Your answer
Please describe relevant educational background (degrees, areas of study, majors, etc.):
Your answer
What language(s) other than English do you use? Please include your level of proficiency with speaking, reading and writing in each language.
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Your answer
References: Please provide information for 2 references other than family members.
Reference 1 Name
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Your answer
Reference 1 Email
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Your answer
Reference 1 Phone
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Your answer
Relationship to Reference 1 (organization, length of time known)
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Your answer
Reference 2 Name
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Your answer
Reference 2 Email
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Your answer
Reference 2 Phone
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Your answer
Relationship to Reference 2 (organization, length of time known)
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Your answer
Please include a detailed list of previous volunteer experience, including organization name, length of service, roles/duties.
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Your answer
Please describe why you would like to volunteer with KCHA.
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Your answer
Please indicate areas of interest in the following departments/units (check all that apply).
Direct Patient Services
Surgical Services
Imaging Services
Emergency Department
Book Cart
Medical Surgical Units
Women's Health
Healing Touch (additional training required)
Department Support Services
Education
Office Help
Marketing Assistant
Maintenance
Cancer Center
Fundraising
Gift Shop
Annual Fundraiser
Other Special Fundraising Activities
Community Outreach
Brochures and Publications
Parades and Community Event
Please indicate days and times you are available to volunteer. Please include the total number of weekly hours you would be interested in working (e.g, 10 hours/week, Mondays and Wednesday, 12-5PM):
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Your answer
There are some positions at the hospital that are off limits to people convicted of certain criminal offenses. Please indicated if you have been convicted of a criminal office (misdemeanor or felony) and provide more details here:
Your answer
Membership Preference
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Active Member: $10/year; min of 10 hours of volunteer service annually
Sustaining Member: $10/year; no min service per year
Patron Member: $50/year; no min services per year
How did you hear about us?
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KHCA Website
Family/Friend
Newspaper
Radio
Facebook
Other
If other, please specify:
Your answer
A copy of your responses will be emailed to the address you provided.
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