Northeast Health Volunteer Application

Where would you like to volunteer?
Title First Name Last Name
Middle Initial Preferred Nickname
Date of Birth Are you over 18 Years Old?
Address City State Zip
Home Phone Work Phone Cell
I prefer to receive calls at E-mail Address
Education (check all that apply)
Prior Volunteer Experience
How did you hear about volunteering at our facility?
If someone referred you, please provide person's name
Availability (Please check the times you are available for a volunteer assignment)
Sunday Monday Tuesday Wednesday
Thursday Friday Saturday
Earliest date you are able to start Indicate area of greatest interest
Department or Program/Area of most interest
Special skills/talents: (e.g., languages, computer knowledge, etc.)
Name of Emergency Contact Relationship Phone
Have you ever been convicted of a crime? If yes, provide crime, court & date of conviction
Are you required to volunteer for community service? If yes, please explain
Please supply two (2) personal/business references (no relatives, please)
Name Relationship Phone Address
Please describe in a brief paragraph why you are interested in volunteering

I certify that the statements made in this volunteer application are true and correct, and have been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest, and I release the hospital from any liability whatsoever for supplying such information.

I understand that I will not be paid for my services as a volunteer.

I have received the hospital's volunteer policies and I agree to abide by the volunteer personnel polices of the hospital. I pledge my loyal and wholehearted service to and its patients. I will abide by their requirements and I will hold in confidence all information coming to my knowledge of hospital and patients' affairs.

Your Signature

If you are a student, please indicate name of high school/college
Address Telephone
Year you will graduate Date volunteer assignment will end
Grade Average Will you receive school credit
List majors of study (if applicable)
Degree Pursuing? (if applicable)
Career interest(s)
Parent/Guardian Name
Contact Information:
Home Phone: Business Phone: Cell Phone:
Parent/Guardian E-mail

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