Volunteer Application

Magnolia Regional Health Center - Volunteer Application


Last Name	First Name	Middle Name	Social Security Number


Home Address	City	State	Zip	Home Phone

Position You Are Volunteering For:

Are You Willing to Be:


	Regularly Scheduled		On Call		Substitute Basis

Days Available:


	Monday		Tuesday		Wednesday		Thursday		Friday


Approximate Hours Available:

Health History:

Have you ever had or been told that you had:


	Yes No


a.	Dizziness, fainting spells, epilepsy, severe headaches, stroke, or any disease or disorder of the brain or nervous system?


	Yes No


b.	High blood pressure, chest pain, shortness of breath, heart trouble, stroke, swelling of the legs or ankles, or rheumatic fever?


	Yes No


c.	Back injury, back sprain or strain, or another condition of the spine?


	Yes No

Have you ever been treated for nervousness, nervous breakdown, emotional illness, or alcohol or drug abuse?

Please give us some information about yourself. What are your interests? Why are you interested in volunteering at the hospital? Do you have specific ideas about how you would like to spend your volunteer time? What are they? We want to get to know more about you. (Optional)

I hereby certify that all statements and answers I have provided are complete and true.


Signature	Date