Volunteer Application
Medical Volunteer Information
Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Languages fluently spoken in addition to English
Are you a licensed medical or mental health professional?
Yes
No
Emergency contact person
First Name
Last Name
Emergency contact phone number
Format: (000) 000-0000.
What type of experience do you have?
Receptionist
Executive Administrative Specialist
Equine Therapist
Equine Certification
Occupational Therapy Student
Social Medica
Marketing
Legal
Life Skill Class
Mental Health Therapist
Drug and Alcohol Therapist
Medication Aide
Fundraising
Event Planning and Organizing
Mentor
CPR/First Aid
Grant Writing
Other___________________________________________________________________________________
Please indicate highest level of education
Please Select
Some High School
High School Graduate
Trade/Vocational/Technical
Some College
College Graduate
Some Post Graduate Work
Work Status
Please Select
Working
Actively looking for a job
Retired
Matching with Need
Please indicate highest number of hours you are able to volunteer in a day
Please Select
4
6
8
12
Are you able to volunteer full-time?
Yes,
No, only part-time
Other Information
Signature
Submit
Submit
Should be Empty: