Volunteer Services Application

Volunteer Application
Thank you for your interest in applying for the "Full Hearts" volunteer services application at Patterson Health Center. We are dedicated to the well being of our patients, staff and volunteers and we are so pleased about your interest in joining us. Please fill out this application and we will get back with you shortly.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Primary Phone #
Format: (000) 000-0000.
Text Message?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Shirt Size
Person to Notify In Case of Emergency:
Name

First NameLast Name
Relationship
Phone
Format: (000) 000-0000.
Your Interests: (Select all that apply)

Other
In a few sentences, please describe why you wish to volunteer at PHC
* All applicants: My signature indicates all above information to be true and correct to the best of my knowledge. I agree that (1) any offer of volunteer service is at the sole discretion of Volunteer Services coordinators and conditional upon my timely and successful completion of background, health and training requirements; and (2) voluntary services is given freely and without expectation of payment for services performed.
Applicant Print & Sign
Parent/Guardian of Minor Applicant: My son/daughter has my permission to apply for and participate in the Patterson Health Center Volunteer Services program. In the event that my son/daughter becomes a participant, I hereby give permission for them to (1) attend training and to serve as volunteer at PHC, and (2) to have PHC administer emergency medical treatment to my son/daughter in the event that he/she is injured wile participating and efforts to contact me

Parent/Legal Guardian Print & Sign
Signature
Please verify that you are human
Should be Empty:

Volunteer Application