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Volunteer Application

Pediatric Interactions Inc. is an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or physical or mental disability.

First Name*

Last Name*

Email*

Phone*

Home Address:

Street*

City*

State*

Zip code*

Additional Information:

How did you hear about Pediatric Interactions?*

How many hours are you available to volunteer?*

First date available to start volunteering?*

Projected End Date (if applicable)?

Students:

Degree seeking:

Outside of any educational program(s), what other related experience do you have in the field?*

Other area(s) of interest:

Do you speak other language(s) besides English?*

Yes

No

If Yes, which language and what is your level of fluency?

Will you be able to perform the essential functions for the position you are applying for with or without reasonable accommodations?*

Yes

Yes with accommodations listed below

Accommodations (If answered yes above):

What specific experience(s) would you like to gain through this opportunity at Pediatric Interactions?*

Describe your long-term goal(s)?*

I acknowledge that I am not a minor and am over 18 years old. Otherwise, I understand my parent/guardian must give consent by contacting Office@PediatricInteractions.com*

Yes, I am over 18

I am a minor and a parent/guardian will contact Pediatric Interactions as requested

CERTIFICATION & AUTHORIZATION

The above information is true and correct. I understand that, in the event of my employment by Pediatric Interactions Inc., I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize Pediatric Interactions Inc. to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to Pediatric Interactions Inc. and will hold Pediatric Interactions Inc. and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize Pediatric Interactions Inc. to obtain any credit , consumer and/or criminal checks. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with Pediatric Interactions Inc. is intended to create an employment contract between myself and Pediatric Interactions Inc. under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by me or Pediatric Interactions Inc. at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9.

I hereby acknowledge that I have read and agree to the above statements.*

I do not agree to the above statements.*