Adult Volunteer Application Form
  1. Name*
    Please enter your full name.
  2. Mailing Address*
    Please enter your street address.
  3. City*
    Please enter a city name.
  4. Zip*
    Please enter a zip code.
  5. Day Phone*
    Please enter a phone number where we can reach you during the day.
  6. Evening Phone
    Please enter a phone number where we can reach you in the evening.
  7. Best time to call
    If you have a preference, please tell us the best time to reach you.
  8. Email*
    Please enter a valid email address (e.g. youraddress@yourdomain.com).
  9. Do you check email regularly?*
    Please let us know whether you check your email regularly. This allows us to use the best option possible for contacting you.
  10. Birthday*
    Please enter your date of birth.
  11. Over 18?*
    Please specify whether you are over 18 years old.
  12. Name and address of person to be contacted in an emergency*
    Please enter the full name and address of a person we may contact in case of an emergency.
  13. Relationship*
    Please specify the relationship you have to your emergency contact.
  14. Phone*
    Please enter a phone number where we can reach your emergency contact.
  15. Primary Physician
    Please enter the name of your primary care physician.
  16. Primary Physician Phone*
    Please enter the phone number for your primary care physician.
  17. How did you learn about our volunteer program?
    Please tell us how you learned about Lodi Health's volunteer program.
  18. Volunteer position/experience desired
    Please tell us how you'd like to help Lodi Health.
  19. What periods throughout the year are you unavailable?
    Please let us know if there are any periods throughout the year during which you would not be able to volunteer.
  20. Have you ever been previously employed or volunteered at Lodi Health?*
    Please select the appropriate answer.
  21. Briefly state why you would like to volunteer with Lodi Health*
    Please enter your reason for wanting to volunteer.
  22. Days/hours of week available*
    Please let us know the days of the week and the hours you would be available to volunteer.
  23. Are you available throughout the year?*
    Please select the appropriate answer.
  24. Previous volunteer experience
    Please tell us about any previous experience you have as a volunteer.
  25. Previous work experience
    Please tell us about your previous work experience.
  26. Please indicate below the skills and/or experience you possess and would be willing to utilize in volunteering at Lodi Health*




















    Please select the skills you'd be willing to lend in your volunteer work for Lodi Health.
  27. Please list other skills and/or experience*
    Let us know about any other skills/experience that would be available if you volunteer for Lodi Health.
  28. Do you speak a langouge other than English fluently?
    Please select the appropriate answer.
  29. If so, what language(s)?
    Let us know about other languages you speak fluently.
  30. Community Affiliations (clubs, other organizations)
    Let us know about other community organizations you are involved with.
  31. Have you ever been arrested or convicted of a felony or misdemeanor?*
    Please select the appropriate answer.
  32. If so, please explain the nature of the charges, when and disposition
    Please enter the requested information.
  33. Please list two references other than family (Name, Address, Phone)*
    Please provide two references.
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    To help us avoid SPAM, please enter the security code
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  35.