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Volunteer Form

Mr.   Mrs.   Miss   Ms.
Name*:
Address*:
City*:
State*:
ZIP*:
Best Phone Number*:
Email*:
Age*: Under 18   Over 18  REQUIRED
Birthday Month*:
Day*:
Year (optional):
Name of Employer:
In case of emergency, notify*:
Phone*:

Related Experience

Volunteer:
Employment*:
Education/Special Training*:
How did you decide to volunteer at Craig Hospital:
Referred By:
Type of service preferred:
How long will you volunteer:
Preferred start date:
Total hours available each week:

Preferred work schedule (check days available and insert hours):

Monday to
Tuesday to
Wednesday to
Thursday to
Friday to
Saturday to
Sunday to
Comments:

Interest Areas/Skills (check all that apply):

Physical Therapy Gardening/Horticulture
Occupational Therapy Sewing
Tech Lab Clerical/Phones
Crafts/Hobbies Giftshop
Water Sports Special Projects/Events
Outdoor Recreation Music/Entertainment
Foundation Research
Nursing
Additional information you want us to know about:
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Personal References

1. Name: Relationship: Phone:
2. Name: Relationship: Phone:
3. Name: Relationship: Phone:
Are there any work activities you must avoid*? If yes, explain: YES   NO  REQUIRED
 
Are you presently under medical care for the above activities or conditions*? If yes, explain and provide name and phone number of current physician: YES   NO  REQUIRED

 *I agree to email a copy of MMR (measles, mumps and rubella) to JStelleyVirden@CraigHospital.orgREQUIRED

 * Required Fields