Junior Application - Hawkins County Memorial Hospital

Please complete this application form if you are interested in Volunteering with us as a Junior Volunteer (ages 14-18 not in college). Once you complete the form, click the submit button at the bottom. You will receive an automated email with further details. If you do not supply an email address on your application, we will contact you by phone in approximately 2-3 weeks to confirm if we have a placement available and let you know the next steps.

Name and Address

First Name:

Last Name:

Middle Name or Initial:

Preferred First Name (if different):

Address 1:

Address 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

OK to call me here

Email address:

Please indicate your scrub top size here:

Parent/Legal Guardian/Emergency Contact

1

2

First Name:

Last Name:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Demographic Information

Date of birth:

Criminal Offenses - I have...:

U Number:

Have you volunteered before with Ballad:

Yes

Availability

Please specify days and times that you would like to Volunteer.

Describe Your Interests and Goals

We will consider this information when assigning your placement if at all possible. Please note that all areas mentioned may not be available.

Are you required to volunteer?:

Yes

Please tell us why you are interested in Volunteering with us and list 2-3 goals you hope to achieve while Volunteering.

I AGREE:

That all information provided is true and accurate to the best of my knowledge. If accepted into the Junior Volunteer Program, I agree to complete all additional requirements and follow all guidelines set forth.

I Agree

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