Junior Volunteer Application Form

Please complete this application form if you are under the age of 17 and interested in becoming a Lake Region Healthcare Junior Volunteer. (All Junior Volunteers must be currently in 7th grade or beyond to participate.) Once you complete the form, click the submit button at the bottom.


Name and address


Parent/Guardian Name(s)


Parent to Contact, If Necessary

Please include your parent's name and phone best to be reached at here:



Home Phone Number


Cell Phone Number


Demographic Information


Hobbies, Skills & Special Interests

Please explain your hobbies, skills and special interests.



Schedule Conflicts

For summer scheduling purposes, please list any schedule conflicts (band lessons, church camp, etc.)



Are work activities or conditions you must avoid?

Please explain any any work activities or conditions you must avoid.



Teacher, Pastor or Role Model Reference

Please list 1 teacher, pastor, or other role model whom we may contact for a personal reference.