Samaritan Health Ministries Volunteer Application Form

Please complete this application form if you are interested in becoming a Samaritan Health Ministries volunteer. Once you complete the form, click the Continue button at the bottom.

Contact Information

First name:

Last name:

Street 1:

Street 2:

City:

State:

* Zip: *

Cell phone:

Demographics

Date of birth:

Age:

Gender:

If Attend, name of Church:

Are you bilingual?:

Skills & Experience

License #:

License Expiration:

Have you volunteered elsewhere? If so, Where?

Skills & Experience

Why do you want to volunteer at Samaritan Health Ministries?

Skills & Experience

Please list any other skills or experience (such as website design, marketing, writing, fundraising)

Availability

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

Assignment Preference

The following volunteer assignments may currently be available. You may click the assignment names to learn more about that assignment. Use this list to rank your top three assignment choices.

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Cell phone:

Relationship:

Employer/Education

Please list your current or most recent employer or school, if applicable.

Employer name:

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

EMail

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however 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

Recruitment appeals

Referrals

How did you hear about us?

I Agree

I understand and agree that submitting this application form does not automatically register me as a Samaritan Health Ministries 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 the form is true and accurate.

I Agree