Please complete this application form if you are interested in becoming a Mills-Peninsula Health Services volunteer. Once you complete the form, click the submit button at the bottom.



Please list your current or most recent employer, if applicable.


Background Check and /or public record search:

Have you ever been convicted or charged of a crime?*

*Existence of convictions and/or charges will not necessarily disqualify an applicant for employment; however, failure to fully disclose requested information may be considered falsification and will result in an offer being rescinded or may result in termination of employment upon discovery at any time during employment.


Briefly explain how you heard about us, your reasons for volunteering, and any other volunteer experience you may have.


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


List two persons NOT RELATED TO YOU who have knowledge of your character and/or education. Family members will not be considered. Contacting references is part of our process and feedback is a factor in our decision making process.

Emergency Contact

In the event of an emergency whom should we notify?

Personal Physician

Signature: Sign at Informational Meeting

Applicant's signature ___________________________________ Date: ___ ___/___ ___/___ ___

Please read the following statements. Sign below:

1. I understand and agree that submitting this application form does not automatically register me as a Mills-Peninsula Health Services volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.
2. By submitting this form, I attest that the information I have provided on the form is true and accurate to the best of my knowledge. I understand that any error or omission may result in the Auxiliary rejecting my application for volunteer service.
3. If accepted, I agree to volunteer minimally 4-hours, once per week, for a year of service.