St. Mary's Nutrition Center, Volunteer Application

First Name

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Last Name

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Parent or Guardian's name (if under 18)

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Date of Birth

My current age

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Home phone

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Cell phone

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Email address

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Home address

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Mailing address (if different)

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Office/Business/School name/location (if applicable)

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Best way and time to contact you

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Are you interested in one-time, occasional, or regular volunteering?

One-time
Occasional
Regular

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What are you interested in doing as a volunteer?

Please check all that apply.

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Skills or interests that you might like to offer:

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Prior volunteer or work experiences (if applicable), especially any experience with children and youth:

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Memberships in community organizations or other activities you are involved in:

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Do you have physical or mental health conditions that should be taken into consideration before determining a volunteer assignment?

If so, please explain

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Generally, what days of the week and times do you want to volunteer?

	Morning	Afternoon	Evening	Varies
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please enter one response per row

If there are specific times you know you are available or unavailable, please enter below.

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Name of FIRST reference and phone number

School, volunteering, employment supervisors, or clergy are acceptable references. Do not list friends, relatives, or neighbors.

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Name of SECOND reference and phone number

School, volunteering, employment supervisors, or clergy are acceptable references. Do not list friends, relatives, or neighbors.

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Name of PRIMARY emergency contact, phone number, and relationship to you

Please list the name and phone number for a relative or friend to contact in an emergency. Please note their relationship to you (spouse, child, sibling, friend, mother, sister, etc.).

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Name of SECONDARY emergency contact, phone number, and relationship to you

Please list the name and phone number for a relative or friend to contact in an emergency. Please note their relationship to you (spouse, child, sibling, friend, mother, sister, etc.).

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Do you have family members or friends that work for our organization?

If so, please note their names and relationship to you.

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By entering your name below you attest to this form and the statement below

As a volunteer/volunteer applicant of the St. Mary's Health System, I understand and agree that any confidential information regarding patients, residents, employees, visitors, and fellow volunteers, or any other information which is disclosed to me or that I learn or observe, is confidential. I understand that if I disclose any such confidential information that this could lead to disqualification as a volunteer applicant or dismissal as a volunteer. All information provided in this application is accurate and I agree that St. Mary's Health System may contact my references as appropriate and that a background check may be conducted.

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By entering your name below you grant St. Mary's Health System permission to use your image if photographed or video taped during volunteer service for public relations purposes.

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