Volunteer Application Form

Complete the Volunteer Application Form and click "submit" at the bottom of page. Thank you for your interest in volunteering at Mercy Regional Medical Center. We will reach out to you once we have had the time to review.

Contact Information

First name:

Last name:

Title:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Emergency Contact Information

First name:

Last name:

Home phone:

Cell phone:

Availability

Please indicate the days and times you are usually available to volunteer.

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

I would like to serve up to:

hours:

Addition Information:

Allow other volunteers to see when I am scheduled

Interests and Skills

Why do you want to volunteer?

Volunteer Assignment Interests

What are you interested in doing as a Mercy Volunteer? Is there anything that you do not feel comfortable doing?

Account Password:

Please create a password:

Please enter a password that:

Is between 6 and 30 characters long

Password:

Confirm password:

Agreement Section

I understand and agree that submitting this application form does not automatically register me as a Mercy Regional Medical Center volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and accurate

I Agree