Volunteer Application - Weiss Memorial Hospital

Title:

Mrs

First Name:

Last Name:

Zip Code:

Street Address:

City:

State:

Email:

Phone:

Date of Birth:

Which one are you?:

Over 18 + HS Diploma or Equivalent

High School Student between 14-18

Why are you interested in volunteering?:

Please send me periodic health related information and updates.

Yes

Emergency Contact Information

Please list someone we can contact in case of an emergency.

Emergency Contact Name:

Emergency Contact Number:

Family doctor:

Family doctor Phone Number:

How did you learn about our Volunteer Program?:

If other, please specify:

Work Experience

(Important to complete for successful placement)

Occupation:

Are you currently employed:

Yes

At What level?:

Please list any education, special training, or talents you have which would be significant as a volunteer:

Please list any previous volunteer work experience including community affiliations and / or offices held:

Please provide a two recommendationLetters

(Important to complete for successful placement)

Personal Reference 1

Full Name(Personal Reference 1):

Phone Number (Personal Reference 1):

How Long have you known them?:

Upload Recommendation Letter Here:

Personal Reference 2

Full Name(Personal Reference 2):

Phone Number (Personal Reference 2):

How Long have you known them?:

Upload Recommendation Letter Here:

Do you have any physical/developmental concerns that might keep you from performing Volunteer tasks:

Yes

if yes , please explain:

For Health Professionals:

Weiss Memorial Hospital Volunteer Application

Volunteer Signup Form

Emergency Contact Information

Work Experience

Please provide a two recommendationLetters

Personal Reference 1

Personal Reference 2

PLEASE SELECT DAYS & TIMES YOU ARE AVAILABLE