Please complete this application form if you are interested in becoming a Chesapeake Regional Medical Center volunteer. Once you complete the form, click the Continue button at the bottom.

Contact Information

First name:

Last name:

Street 1:

City:

State:

Zip: *

Home phone:

OK to call me here

Cell phone:

Email address:

Age:

Demographic Information & Personal

Date of birth:

Gender:

Polo Shirt Size - Cost of each shirt is $15.00 - cash or check

Essay Section

In 250-500 words, why are you interested in volunteering at Chesapeake Regional Healthcare?

Sessions

CRMC is offering three Monday thru Thursday Student Volunteer sessions -

9am-1pm or 1pm-5pm

Please list the session and time that you prefer.

June 27- July 14 (Three Weeks)

July 18- August 4 (Three Weeks)

August 8- August 18 (Two Weeks)

Emergency Contact

First name:

Last name:

Title:

Street 1:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

Relationship:

Health Concerns/ Restrictions

Please provide any health concerns or restrictions that include any conditions that may necessitate special assignment.

Vaccinations

In order to Volunteer at Chesapeake Regional Medical Center, you must be fully vaccinated against Covid and have had a recent TB Test.

Are you fully vaccinated for Covid?

Have you had a recent TB Test?

You will need to bring documentation from your Family Physician as proof of your

vaccinations and TB Test.

I Agree

I understand and agree that submitting this application does not automatically register me as a Chesapeake Regional Medical Healthcare 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.

By submitting this form, I attest that the information I have provided on this application is true and accurate.

I Agree