Apply to be a friend of CMH!

* required field

Applicant Name

* First

* Last

Middle

* Address

* City

State

* Zip

Primary Phone

Secondary Phone

* E-mail address

Education

Highest level of education completed

Special Skills or Training

Professional Licenses and/or Certifications

Work Experience

Job Title or Position

Kind of Business

Duties

Job Title or Position

Duties

Hobbies or Special Interests

Comments

I have read the above information and acknowledge the answers to be true and correct to the best of my knowledge. I agree to work within the guidelines of the volunteer program and to protect the right of confidentiality of all patients and staff. As a volunteer, my services are rendered on a gratuitous basis.

* Signed (type name)

* Date

Volunteer Experience

Reason for Volunteering

* Type of Service Preferred

* Days of Week Preferred

Work Hours Preferred

Are you willing to be called for temporary assignments in addition to your regular volunteer service?

Yes

Is your physical activity limited in any way?

Yes

If yes, please explain

Person to be contacted in case of accident or illness

Name

Address

Phone

Relationship

Application

Apply to be a friend of CMH!