Volunteer Application

To apply to become a LincolnHealth Volunteer, please complete this application form and click the Continue button at the bottom.

Contact Information:

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

OK to call me here

Email address:

Spouse's name:

Personal Information:

Date of birth:

Gender:

Skills & Experience:

Previous Volunteer Experience:

Please list any current or past volunteer experiences:

Education/Employment:

Education:

Work Experience:

School:

Please list any professional licenses or certifications current or past.

Why are you interested in Volunteering at LH?

Referral Source:

Please explain why you want to volunteer at LH.

Availability and When can you serve?

Mon

Tue

Wed

Thu

Fri

From:

To:

My availability is:

Assignment Preference:

References:

1

2

First name:

Last name:

Home phone:

Cell phone:

Email address:

Relationship:

Emergency Contact:

In the event of an emergency whom should we notify?

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

Background Check:

A Criminal background check will be conducted by MaineHelath for all volunteers.

Have you ever been convicted of a felony or any other violation of the law? If Yes, please explain.

Health Consideration:

Do you have any limitations or health conditions which should be taken into consideration before determining a volunteer assignment? All potential volunteers will be cleared through MaineHealth Employee Health Service.

If yes, please explain:

I Agree

I understand and agree that submitting this application form does not automatically register me as a LincolnHealth Volunteer, and 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