Name

Address

Address 1

City

ZIP / Postal Code

State / Province

Country

Contact Information

Phone

Are you at Least 18 years of age?

Are you at Least 18 years of age? If yes, please check the box.

Emergency Contact Name

Name

Emergency Contact Information

Which hours would you prefer to volunteer?

Morning

Afternoon

Evening

How many hours per week would you like to volunteer?

Reference #1

Reference Name

Reference

Reference #2

Reference Name

Reference

Volunteer Interests

The following are areas in which we have volunteer needs. Select all that interest you. If you do not see a specific opportunity you are looking for, please indicate your special interest or talent in the field below.

Maintenance & Housekeeping

mowing, trimming

outdoor maintenance/yardwork

small carpentry projects

painting

Clerical

stuffing envelopes/folding mailers

answering phones

computer data entry

general office work

Lifeline

installing Lifeline units

Information & Wayfinding

receptionist in surgery waiting area

greeter for health screenings or flu clinics

distributing patient satisfaction surveys

assisting with hospital tours

greeter for information desk

Hospice

hospice volunteer

Other

cardboard collection

assist with educational programs

childcare in hospital setting

I pledge to keep all staff/resident/patient/tenant information in strict confidence. I understand that any breach of this confidentiality will result in immediate dismissal.

Volunteer Application

Volunteer at Orange City Area Health System!

Contact Information

Reference #1

Reference #2

Volunteer Interests