Application for Junior Volunteer Service

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Home Phone
Cell Phone
Contact in Case of Emergency
First Last
Emergency Contact Relationship (ie Parent, Spouse etc)
Emergency Contact Phone
Name of School
Grade
Year of Graduation
Career Interest
Volunteer Experience
Work Experience
What is your reason for volunteering?
Do you have any relatives employed or volunteering at Mather Hospital
- Yes
- No
Please provide information
References
Reference #1 - Name
First Last
Reference #1 - Phone Number
Reference #1 - Address
Street Address Address Line 2 City State / Province / Region
Reference #2 - Name
First Last
Reference #2- Phone Number
Reference #2 - Address
Street Address Address Line 2 City State / Province / Region
I prefer:
- Patient contact
- Non-patient contact
- Where needed
Applicant Initials*
Parent Initials*
Parent signature will be required at time of interview.
Date: 12/11/2019

Opportunities for volunteers are provided without regard to race, color, sex, age, religion, national origin, marital status, sexual preference/orientation, qualified disability and veteran status.

Application for Junior Volunteer Service

References

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