When your application is complete, click the submit button at the bottom.

Teen Applicants: You must have reached your 14th birthday to apply and must print and give a recommendation form to your Guidance Counselor. Teen applications will not be considered until the Guidance Counselor recommendation form is received.

Contact Information

Education and Availability

If you are only available for certain dates, or there is a time of year you are not available, please indicate here.


Please list three personal or professional references who are not relatives. Teens must use your Guidance Counselor as one of your references. Print and give the recommendation form to your Guidance Counselor.


Please list your employment history for the past ten years. If there has been no employment indicate none.


I certify that the answers given by me to the foregoing questions and statements are true and correct. I agree that I will not claim or hold Rutland Regional Health Services in any respect if my volunteerism is terminated because of the falsity of statements, answers or omissions made by me in this questionnaire. I authorize employers, companies, schools or persons named above to give any information regarding my employment or volunteerism, together with any information they may have regarding me whether or not it is in their records. I hereby release said employees, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information. I also understand a conditional offer of a volunteer position may be based on results of a later medical examination. In addition, if accepted for the volunteer program, I hereby agree to abide by the rules and policies of Rutland Regional Health Services.

Further, I understand that any volunteer position is at will and is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer. I also understand, acknowledge and agree that my volunteer position is not subject to any RRHS/RRMC handbook, and since I am holding the position at will, I can be released from that position at any time for any reason.

SIGNED______________________________________________________ DATE_________________________