Volunteer Application Form

Please complete this application form if you are interested in becoming a volunteer with Fairview Range Volunteer Services Organization at Fairview Range Medical Center. 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:

* Zip: *

Home phone:

Work phone:

OK to call me here

Cell phone:

OK to call me here

Demographic Information - Birthdate

You must be at least 18 years old to volunteer.

Date of birth:

(year optional)

Email Preferences

We routinely use email to communicate with our volunteers; however, we will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

Email address:

What kinds of email would you like to receive?

Electronic newsletters

Announcements

Work History

List your current or most recent employer, job title, and duties.

Employer name:

City:

State:

Work phone:

OK to call here

Current or most recent job title, and duties.

Previous volunteer experience

List any previous volunteer experiences you have had.

I want to volunteer at Fairview Range because

Availability

Use the checkboxes to indicate the days and times you are usually available to volunteer

Assignment Preferences

Use the checkboxes below to show which assignment areas you may be interested in. You may choose more than one. Click on the assignment to learn more about job duties, qualifications, and availability. If you are open to any assignment, leave blank.

References

Two (2) references are required. Please provide names and phone numbers of 2 non-relatives. References will be checked before orientation is scheduled.

1

2

First name:

Last name:

Home phone:

Cell phone:

Emergency Contact Information

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

OK to call here

Relationship:

Terms and conditions for applying

The information submitted in this application is true and accurate to the best of my knowledge. If approved for consideration, I understand I will be expected to abide by the policies and standards of Fairview Range Medical Center. Prior to my placement in a volunteer position, I understand that I will have to attend a new volunteer orientation, submit a background study form as required by law, and complete a pre-placement interview and health screening.

I Agree