Volunteer Application Acknowledgement

Please complete this application form if you are interested in becoming a MelroseWakefield Healthcare Volunteer. Once you have completed the form, click the submit button at the bottom.

Name and Address

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

OK to call me here

Email address:

Date of birth:

Schedule Information

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

Assignment preference

Please choose from the available assignments on our website and briefly list skills that make you a good candidate for this position.

Emergency Contacts

Please provide the contact information for 2 Emergency Contacts.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

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

Email address:

Relationship:

Employment History

List current and past employers beginning with most recent.

1

2

Employer name:

Street 1:

City:

State:

Zip:

Work phone:

Volunteer Experience

Have you had any previous experience as a volunteer?

Please list volunteer experience here:

References

Please provide the name of one person that is not related to you.

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

* OK to call here

Work phone:

Cell phone:

OK to call here

Other phone:

Email address:

MelroseWakefield Healthcare Volunteen Application

I affirm that the information on this application is true and complete. I understand that before I begin my volunteer service, I will be interviewed, complete an orientation and I agree to participate in the MW Healthcare full year volunteer program. Submit a health screening form proving immunity to the chicken pox, measles, mumps and rubella or have a titre test drawn. I will also complete the mandatory TB test prior to my volunteer assignment. PLEASE NOTE: The FLU SHOT is MANDATORY during flu season.

I Agree