Please complete this application form if you are interested in becoming a University of Maryland Baltimore Washington Medical Center volunteer. Once you complete the form, click the Continue button at the bottom.

Name and address

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Phone #1 phone:

Phone #2 phone:

Email address:

Have you volunteered at any hospital in the past? If yes, please name which hospital, your job duties, and the time period you were there.

Limitations

Do you have any physical or emotional limitations we must consider in your volunteer placement? If yes, please explain.

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

I would like to serve up to:

hours:

Why do you want to volunteer at the University of Maryland Baltimore Washington Medical Center (UM BWMC)?

References

Please select two personal or professional references and include contact information.

1

2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Email address:

Relationship:

Have you ever been convicted of a criminal offense? If yes, please fully explain.

Emergency Contact

Please provide an emergency contact

First name:

Last name:

Home phone:

Cell phone:

Employer/Business Information

Employer name:

City:

State:

Describe your participation in other volunteer activities and organizations

Education Information

High school:

Start Date:

Language

Please list any languages besides English that you speak fluently

Volunteer Information

Is your interest in our volunteer program in conjunction with a school or court requirement?

Past Volunteering Activities

Have you volunteered at a hospital in the past? If yes, please name which hospital, your job duties, and the time period you were there.

Application Form Agreement

I hereby affirm that my statements and answers to all questions in this application are true and correct, and that I have not knowingly withheld any fact or circumstance which, if disclosed, would affect my application unfavorably.

I Agree