Adult Volunteer Application Form
Please complete this application form if you are over the age of 17 and are interested in becoming a Lake Region Healthcare Adult Volunteer. Once you complete the form, click the submit button at the bottom.
Name and address
First name:
*
Last name:
*
Title:
Choose
Dr.
Mr.
Mrs.
Ms.
Street 1:
*
Street 2:
Street 3:
City:
*
State:
Choose
MN
*
Zip:
*
Telephone Number
Home phone:
*
Cell Phone Number
Cell phone:
Email
We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email.
Email address:
What kinds of email would you like to receive?
Electronic newsletters
Recruitment appeals
Demographic Information
Date of birth:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
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15
16
17
18
19
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25
26
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28
29
30
31
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
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1999
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1995
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1993
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1991
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1989
1988
1987
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1982
1981
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1975
1974
1973
1972
1971
1970
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1968
1967
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1962
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1948
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1941
1940
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Gender:
Choose
Female
Male
*
Availability
Please indicate the days and times you are usually available to volunteer.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
I would like to serve up to:
*
hours:
Choose
Daily
Monthly
One time
Weekly
*
Previous Work Experience
Please explain your previous work experience
Hobbies, Skills & Special Interests
Please explain your hobbies, skills and special interests
Please list the areas you are interested in
Cancer Center Greeter/Snack Bar
Gift Shop Clerk
Courier Driver
Community Garden
Rock Steady Boxing
Patient and Family Advisory Council
Mill Street
Sew/Craft
Any activities or conditions you must avoid?
Explain if there are any work activities or conditions you must avoid.
Emergency Contact
Please fill in the requested information for one person to be contacted in the case of illness or injury.
First name:
*
Last name:
*
Street 1:
City:
*
State:
Choose
MN
*
Zip:
Home phone:
*
Work phone:
Cell phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
*
Personal Reference
Please fill in the requested information for one person whom we may contact for a personal reference.
First name:
*
Last name:
*
Street 1:
City:
*
State:
Choose
MN
*
Zip:
Home phone:
*
Work phone:
Cell phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
*
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