General Volunteer Registration
Mountain Hope Good Shepherd Clinic Volunteer Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Volunteer Experience
Name of Organization
*
Address of Organization
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
First Name
Last Name
Details of Volunteer Experience
Personal References
These cannot be relatives.
1. Name
Phone Number
Please enter a valid phone number.
2. Name
Phone Number
Please enter a valid phone number.
3. Name
Phone Number
Please enter a valid phone number.
Interests and Skills
How did you become interested in the Volunteer Program?
Please Select
Individual Contact
Website
Social Media
Do you speak or read another language other than English? If so, what?
Areas of Interest- Select all that apply
Patient Care
Clerical
Pharmacy
Social Services
Mental Health
Maintenance
Fund Raising
Other
Skills- Select all that apply
Customer Service
Accounting
Filing
Teaching
Data entry
Other
Please list computer knowledge (i.e Microsoft Word,etc.)
Days Available
Monday
Tuesday
Wednesday
Thursday
Friday
Hours Available
I authorize the use of any information in this application to enable the Clinic to verify my statements, and I authorize past employers, all references, and other person to answer all questions asked by the Clinic concerning my ability, character, reputation and previous experience. I release all such persons from any liability or damages on account of having furnished such information. I agree to abide by all rules, policies and regulations of the Clinic.
Signature
Date
-
Month
-
Day
Year
Date
Submit
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