Volunteer Application

Please complete this application form if you are interested in becoming a Mary Greeley Medical Center volunteer. Once you complete the form, click the submit button at the bottom.

General Information

Legal First name:

Legal Last name:

Preferred Name:

Street 1:

Street 2:

City:

State:

* Zip: *

Primary phone:

* OK to call me here

Work phone:

OK to call me here

Additional phone:

Email address:

How did you hear about this opportunity:

Why are you interested in volunteering at Mary Greeley Medical Center?

Demographic Information

Are you a current student?:

If yes, name of school::

Are you currently employed?:

1. Yes

2. No

3. Retired

Have you ever been employed or volunteered at Mary Greeley Medical Center? If yes, please provide dates and department.

Skills, Interests and Hobbies

Please share any special skills, interests or hobbies you have.

Computer Skills:

1. Word

2. Excel

3. Access

Skills, Interests and Hobbies:

Background #1

Have you ever been convicted of a crime in this state or any other state other than minor traffic violations?

Indicate answer here::

If yes, please explain:

Background #2

Do you have a record of founded child or dependent adult abuse in this state or any other state?

Indicate answer here::

If yes, please explain:

Availability

Please provide information on frequency and days and times you are available.

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

* How often would you like to volunteer?:

1 time per week

2 or more times per week

Other

If you are a student, which school breaks are you available to volunteer?

Areas of Interest

Please indicate areas where you are interested in volunteering.

Previous Volunteer Experience #1

Please list any past volunteer or work experience that you would like us to be aware of:

Previous Volunteer Experience #2

Please list any past volunteer or work experience that you would like us to be aware of:

Reference #1

Please list two people that can speak of your current abilities, skills and talents for volunteering.

Please do not include relatives.

Relationship to Reference:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Primary phone:

Email address:

Reference #2

Relationship to Reference:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Cell phone:

Primary phone:

Email address:

Emergency Contact

Please provide contact information for at least one emergency contact.

First name:

Last name:

Primary phone:

Other phone:

Relationship:

Agreement

The facts set forth in this application are true and complete. I understand that:

- nothing contained in this volunteer application or in

the granting of an interview is intended to create an

employment contract.

- my volunteer assignment is contingent upon successful

completion of a criminal background check to include

child and dependent adult abuse checks, which requires

a social security number.

- I will be asked to attend orientation to volunteering

and will adhere to all policies set forth by Mary

Greeley Medical Center.

- I will be asked to furnish proof of immunization

records for Measles, Mumps, and Rubella (MMR)and

Varicella (Chicken Pox)vaccinations if

necessary for my volunteer assignment.

- I will be asked to complete a Tuberculosis Blood Test

if necessary for my volunteer assignment.

- Mary Greeley Medical Center is a tobacco free campus,

and I will abide by policies governing such.

- I will be asked to volunteer for a minimum of six

months.

I Agree