General Information

Name
Address
City
State
Zip Code
E-Mail Address
Home Phone
Date of Birth

Why are you interested in volunteering at Good Samaritan?

What grade are you in?

7
8
9
10
11
12

School Name
Homeroom Teacher Name
Guidance Counselor Name

List any extracurricular activities in which you participate.

Guardian/Emergency Contact Information

Guardian 1
Name
Address
City
State
Zip Code
Home Phone
Work Phone
Relationship to You

Guardian/Emergency Contact Information

Guardian 2
Name
Address
City
State
Zip Code
Home Phone
Work Phone
Relationship to You

List any health problems, physical limitations or allergies that you may have.

Volunteer Preferences

What days of the week do you prefer to volunteer?

How many days per week can you volunteer?

What hours are you available to volunteer?

Please select your areas of interest (check all that apply).

Nursing Units
Clerical
Gift Shop
Information Desk
Caring Corner Thrift Shop
Computers
Pharmacy
Same Day Surgery Unit
Emergency Department
Physical Therapy Department
Radiology Department
Other areas of interest

Do you know anyone who currently volunteers at Good Samaritan?

No Yes

Do you know anyone who currently works at Good Samaritan?

No Yes

How did you learn about Good Samaritan's Volunteer Program?