Please complete this application form if you are interested in becoming a Memorial Healthcare volunteer. Once you complete the form, click the submit button at the bottom.

Name and address

Personal Data

Please indicate your date of birth and your social security number.


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

Email Preferences

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.


Please indicate the highest grade level completed.

Current Occupation

Please indicate your current occupation.

Who referred you to Volunteer Sercices

Please indicate who referred you to Memorial Healthcare.


Please list name and contact information for two references.

Emergency Contact

Please list an emergency contact with phone number.

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.


I Understand that MH may investigate my work and personal history and verify all data signed in this application, on related papers and in interviews and I authorize it to do so. This inquiry may include information as to my character, general reputation and personal characteristics, and can include inquires on my criminal history and I consent to the conduct of this inquiry and to the consideration of any statement or reference that are given in response to the inquiry. I Certify that all information is true and correct in this application and related documented is true and complete without qualification. I understand and acknowledge that any misrepresentation, omission and incorrect statement of fact can result in rejection of my application or, if already a volunteer, immediate discharge.