Desert Regional Medical Center Volunteer Application Form
Please complete this application form if you are interested in becoming a Desert Regional Medical Center volunteer in either our Adult or Teen summer programs. Once you complete the form, click the submit button at the bottom.
Name and Address
First name:
*
Last name:
*
Nickname:
Street 1:
*
Street 2:
City:
*
State:
Choose
AB
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip:
*
Home phone:
Parent-Students phone:
Cell phone:
*
Email address:
*
Demographic Information
Please provide your Social Security Number in the open box below. Our system for both transmitting and storing this information is encrypted and secure.
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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Year
2022
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2019
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Age:
Availability
Please indicate the days and times you are usually available to volunteer.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
My availability is:
Choose
Ongoing
Ongoing, except between these dates
Only between these dates
From:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
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29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
to:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
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28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
I would like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
Previous Volunteer Service
Please tell us about any previous volunteer service.
Please tell us where you have volunteered in the past.
Emergency Contacts
First name:
Last name:
Home phone:
Cell phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Partner
Sister
Son
Spouse
Supervisor
Wife
Personal and Professional References
1
2
First name:
First name:
Last name:
Last name:
Home phone:
OK to call here
Home phone:
OK to call here
Cell phone:
OK to call here
Cell phone:
OK to call here
Email address:
Email address:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Partner
Sister
Son
Spouse
Supervisor
Wife
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Partner
Sister
Son
Spouse
Supervisor
Wife
Contacted:
Choose
No
Yes
Contacted:
Choose
No
Yes
Verified:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
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29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Verified:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
3
First name:
Last name:
Home phone:
OK to call here
Cell phone:
OK to call here
Email address:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Husband
Mother
Neighbor
Partner
Sister
Son
Spouse
Supervisor
Wife
Contacted:
Choose
No
Yes
Verified:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
Please Read Carefully!
I understand that I am volunteering at Desert Regional Medical Center and the information provided is true and correct and has been given voluntarily. As part of the agreement, I will be able to work at least (4) hours per week for a period of (6) months or more.
I agree to hold absolutely confidential all information which I may obtain directly or indirectly concerning patients, doctors, or personnel, and not seek confidential information in regard to a patient.
I will make the commitment to:
• Be punctual and conscientious
• Willingly follow the instruction of my supervisor
• Be responsible for fulfilling my commitment to the hospital
• Conduct myself with dignity, courtesy, and consideration of others
• Take any problems, criticisms, or suggestions to the Director of Volunteer Services if unable to resolve with my supervisor
• Endeavor to make my work professional in quality
• Uphold the philosophy and standards of the hospital and interpret them to the community at large
The volunteer Services Department reserves the right to terminate a volunteer for:
• Failure to comply with hospital policies, rules, and regulations
• Continuous absences without prior notification
• Unsatisfactory attitude, work, or appearance
• Breach of confidentiality
• Falsification of time records
My services are donated to Desert Regional Medical Center without contemplation of compensation or future employment and given with humanitarian, religious or charitable reasons. I will not hold DRMC responsible for any claim or damage as a result of injury, illness or other harmful effects or conditions that may arise related to the volunteer services performed. I authorize DRMC permission to give emergency medical treatment to me if ever needed.
I Agree
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