Please complete this application form if you are interested in becoming a Major Health Partners volunteer. Once you complete the form, click the submit button at the bottom.


Date

Enter Today's Date



Name and address


Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.



Availability

Please indicate the days and times you are usually available to volunteer. We Require our Volunteers to commit to a minimum of 6 months.



References


Emergency Contact

In case of emergency, contact:



ACKNOWLEDGMENT

I hereby certify that all information contained in this application is true and correct to the best of my knowledge.

I authorize the investigation of all statements contained in this application as may be necessary in arriving at a volunteer assignment decision, including reference checks and a criminal history background check.

I understand that, in the event of being accepted as volunteer, false and misleading information given through my application or interview(s) may result in discharge.