Kovler Krew Application

Your involvement as a member of the “Kovler Krew”- whether large or small – will help us expand our community presence, educate individuals, corporations and Chicagoland about diabetes and our work at Kovler.  With your help we can affirm our reputation as the national and international leader in diabetes care and research, while serving the needs of those in our communities.

Have further questions? Please contact:

Peggy Hasenauer, Executive Director
Phone: (773) 834-4789
E-mail: diabetes@uchospitals.edu

APPLY TO BE PART OF KOVLER KREW:

Name (required)

Gender

Date of Birth (Must be at least 16 years old.)

Mailing Address
If you are a college student, please give us your permanent address.

City (required)

State (required)

Zip (required)

Telephone (required)

Best time to call Day or Evening

Email Address (required)

________________________________________________________________________________________

Person to contact in an emergency (required)

Address (required)

Relationship (required)

Telephone (required)

(For students under 18) Parents' Name

Parent's Address

City

State

Zip

________________________________________________________________________________________

Employment (required)

Current Work Place (if applies)

Position Held

Have you ever volunteered and/or been employed at the University of Chicago Medical Center?

If yes, when?

________________________________________________________________________________________

Highest Level of Education

School Name

Level Completed

Major/Degree (required)

________________________________________________________________________________________

If you are volunteering for a school requirement, please complete the following:

School Name

Contact Person

Number of Required Hours

________________________________________________________________________________________

What special hobbies, skills, or interests would you like to apply to your volunteering experience?

If you have other volunteer experiences please list the following:

Languages

Where Volunteered

Dates

Type of assignments

Why do you want to volunteer?

How did you learn of our organization?

Type of work you would like (check all that apply)
 InTransit TeenKrew and Ambassadors- Complimenting our InTransit teen program, we will have an advisory panel of teens and ambassadors for community- based efforts.
 Kovler KidsKrew and Ambassadors—Comprised of out Kovler for Kids –an ambassador group who represent the “face” of Kovler and living with diabetes.
 KovlerKrew Grassroots Volunteer Group—Adult-based group interested in giving their time to the community events and programs Kovler participates in.
 Kovler KapitalKrew –Adult-based group who help Kovler raise critical funds for clinical and research efforts.
 KovlerKrew Community –Community-base efforts to improve diabetes care and outcomes on the South Side.

________________________________________________________________________________________

Have you ever been convicted of a criminal offense other than minor traffic violations? (A “Yes” answer will not necessarily result in your disqualification.) (required)

Have you ever been listed or used another name other than one listed on the application? (required)

If so, please list all that apply?

I affirm that the information provided in this application is true and complete to the best of my knowledge. I understand that volunteer applicants will undergo a criminal background check. I consent to take the prevolunteer physical health screening and any such future screening(s) as may be required by the University of Chicago Medical Center. I agree to follow hospital policies and procedures for volunteers as outlined in the Volunteer Handbook. I understand that Volunteers are not covered by Workman's Compensation and that I am responsible for maintaining my own health insurance. I voluntarily offer my services with a clear understanding there will be no monetary compensation and that volunteering does not lead to employment. (required)

Date (required)