Please complete this application form if you are a high school student age 14-17 and interested in becoming a Mills-Peninsula Health Services volunteer. We ask for a minimum of a ONE year commitment to our program, which involves one 3 or 4 hour shift every week. If you are currently a High School Senior and plan to be moving away for college in August of 2020, this may not be the right program for you at this time, as you would not be able to keep the year commitment. You must also print and mail the signed Parent/Guardian form and the signed Teacher form to: Mills-Peninsula Auxiliary, 1501 Trousdale Drive, Burlingame, CA 94010. Applications at this time are only accepted through 5pm on March 31st, 2020, for a June 2020 start date. The next window for applications will be in August of 2020 for a November 2020 start. Thank you.



Background Check

Have you ever been charged or convicted of a crime or arrested for an offense?

*A "Yes" answer will not necessarily disqualify you from Auxiliary service.



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

Emergency Contact

In event of an emergency, please list the name and contact information for parents/guardian and one other emergency contact.

Personal Physician

Signature: Sign at Interview

Applicant's Signature: ____________________________________________________ Date: ______________________

Personal Statement

Please write a 500-1000 word personal statement. Applications not meeting this requirement will not be moved forward in the process.

Please read the following statements.

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. I also understand that there is a minimum of a one year commitment once I begin my volunteering duties.

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.