Volunteer Application


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	ADULT VOLUNTEER APPLICATION FORM


	Name


	Mailing Address

	Day Phone

	Email Address

	Birthday


	City


	Zip

Eve


	Best time to call


	Do you check email regularly?


	Over 18?


	Name and address of person to be contacted in an emergency:


	Relationship


	Phone


	Name and phone number of primary physician:

Phone


	How did you hear about our volunteer program?

If Other, please explain


	Volunteer position/experience desired:


	Have you ever previously been employed or volunteered at Lodi Memorial Hospital?


	Briefly state why you would like to volunteer with Lodi Memorial Hospital:


	Days/hours of week available

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
A.M.
P.M.


	Are you available throughout the year?


	Unavailable time?


	Previous Work Experience


	As a volunteer


		As an employee



		Please indicate below the skills and/or experiences you possess and would be willing to utilize in vounteering at Lodi Memorial Hospital:


	Please list other skills and/or experiences:


	Do you speak a lanuage other than English fluently?


	If so, what language(s)?


	Community Affiliations (clubs, other organizations):


	Have you ever been arrested or convicted of a felony or misdemeanor?


	If so, please explain nature of charges, when and disposition:


	Please list two references other than family (Name, Address, Phone):