Adult Volunteer Application

Complete the form below to join our volunteer team!

First Name*

Last Name*

Address

Street Address *

Address Line 2

City*

State*

Zip Code *

Telephone *

Email*

Date of Birth

Month*

Day*

Year*

Employer Information

First Name*

Last Name*

Address

Street Address *

Address Line 2

City*

State*

Zip Code *

Country *

Telephone

Are you a college/university student?*

In Case of Emergency or Illness

First Name*

Last Name*

Relationship*

Emergency Contact Phone Number *

Why are you interested in our volunteer program?*

Please list any prior volunteer experience:*

Education

Last Year Completed*

Degree

What languages do you speak?*

Volunteer Preferences* Patient Care Office Services All of the Above Other

Schedule Availability

Please list times for each day of the week that you are available.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Agreement

I agree to abide by the requirements and regulations of Palisades Medical Center and the service to which I am assigned. I will serve a minimum of eighty (80) hours after participating in required training. Letters of recommendation will not be issued prior to completion of 80 hours of volunteer time.

Photographic Consent* Yes No

I authorize Palisades Medical Center and the Palisades Medical Center Foundation to use my name and/or photograph in marketing materials to help promote Volunteer Services at Palisades Medical Center.

Retype Full Name For Signature:*

Date*