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auxiliary adult volunteer application youth volunteer application


YOUTH ON-LINE VOLUNTEER APPLICATION
Date:
First Name: MI:
Last Name:
Home Address:
City: State:
Zip Code:
Home Telephone:
Email Address:
Birthdate:
Gender:
Male     Female
Education
Grade
(select one)		 6
7
8
9
10
11
12
Graduate Degree:
Volunteer Experience
Agency
Dates
Describe Duties Performed
Duration
 brief description of work
long term
 short term (1-3 months)
Employer
Employer Phone
Person to notify in an emergency
Relationship
Phone Day Phone Evening
Referred by
Education or special training
Skills
Previous Experience
Interests and Hobbies
Please check the type of volunteer assignment you would prefer:
Patient Contact
Visitor Contact
Clerical
Please check the day(s) and time you are available to volunteer.
A minimum of 50 hours (completed within one year of volunteer service) is required.
Sunday Morning Afternoon Evening
Monday Morning Afternoon Evening
Tuesday Morning Afternoon Evening
Wednesday Morning Afternoon Evening
Thursday Morning Afternoon Evening
Friday Morning Afternoon Evening
Saturday Morning Afternoon Evening
Please include two references (work, school, or professional contact person)
Reference One:
Name
Relationship
Phone
Reference Two:
Name
Relationship
Phone
Are there limitations on your ability to serve as a volunteer?
Yes    No
If yes, please explain limitations:
By submitting this form, I understand that:
I certify that all statements made on this application are true, correct and complete to the best of my knowledge and made in good faith. I understand that any misinformation may cause for termination or disqualification from the Memorial Hospital Volunteer Program.

I will be expected to abide by all the rules and regulations.

I understand that the Volunteer Manager of Memorial Hospital has the right to remove me from serving as a volunteer at any time.

A signature of parent or legal guardian for volunteers under the age of 18 will be required prior to volunteering.
 
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