Application for Junior Volunteer Service

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth*
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
Emergency Contact Email*
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: 02/01/2023

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.

Volunteers are required to be fully vaccinated for COVID-19 before they begin. Documentation of COVID-19 vaccination must be provided.

Application for Junior Volunteer Service

References