Volunteer Application

All fields are required - Please put "n/a" in any blank fields in order for the form to submit

General Information
First Name
Middle Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Cell/Mobile Phone
Birthday month
Birthday day
E-mail
Category you are applying for:	Junior Volunteer (Ages 14-18) Volunteer
How did you become interested in our program?
Service area desired:
Location desired:	To select more than one hold ctrl key down and click
Days available:	To select more than one hold ctrl key down and click
Times available:	To select more than one hold ctrl key down and click
Adult Volunteers - Current/Previous Employment
Company
Position
Company Phone
May we call if necessary?
Junior Volunteers
Name of School
Last Grade Completed
School Counselor
School Phone
Career Interest
School Activities
Emergency Notification
Name
Relationship
Home Phone
Work Phone
Cell/Mobile Phone
Family Physician
Physician's Phone
References (no relatives)
# 1
Name
Address
City
State
Zip
Home Phone
Work Phone
# 2
Name
Address
City
State
Zip
Home Phone
Work Phone

Believing that Charleston Area Medical Center has need of my services as a volunteer worker, I agree to: Hold as absolutely confidential all information which may obtain directly or indirectly concerning patients, doctors, or personnel. I will not seek confidential information in regard to a patient. Give Charleston Area Medical Center, Inc. permission to make a thorough investigation of my past employment and all other facts stated. I authorize and release from liability or responsibility all persons, companies, schools and municipalities supplying any information regarding me whether or not it is a matter of record. My services are donated to Charleston Area Medical Center without contemplation of compensation of future employment and given humanitarian or charitable reasons. By clicking submit you agree to the above terms.