Application for Volunteer Service
After completing the form, click on the Continue button at the bottom.
* indicates a required field.

Name & Address

Profile Information

Check the "Never Been Convicted" box below, if you have never been convicted for the violation of any law.


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

Emergency Contact

Personal Reference

Confidentiality & Volunteer Agreement

I understand that any information that I have access to regarding patients, such as a patient's name, is confidential and must not be repeated to anyone inside or outside of this hospital. I also understand that disclosing patient information in any form can lead to my dismissal as a volunteer.

As a volunteer at Mid Coast-Parkview Health an Annual Fire, Safety, and HIPAA Test is required.

In the event of injury while I am on volunteer duty at Mid Coast-Parkview Health, the hospital has my consent for me to receive treatment in the Emergency Department.

I understand that I must complete an Authorization for Release of Information form to facilitate a background check.

I understand that I must have a Health Assessment with Employee Health.

The information provided on my application is correct and complete to the best of my knowledge and that any false or misleading statements on my application may result in refusal of my volunteer service.