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:

Street 1:

Street 2:

Street 3:

City:

State:

* 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:

Gender:

Availability

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

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:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

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:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship: