Adult Volunteer Application Contact InformationName(Required) First Last Preferred Name Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Cellphone (If different from above)Do You Text?(Required) Yes No Email Address(Required) Enter Email Confirm Email Demographic InformationDate of Birth Month Day Year AgeGender Do you have family members employed by MCH?(Required) Yes No If yes, please list their name(s) and department(s)Preferred Pronouns(Required) She/Her He/Him They/Them Other Volunteer Preferences(Required) Ambulatory Surgery Ambulatory Surgery Registration Chaplaincy Community Wellness Diagnostic Registration Emergency Department Patient Liaison Front Desk Human Resources Nursery (Currently Full) Outpatient Registration Pre-Admission Testing Wayfinding Other Please select your top three (3) options. See descriptions at Volunteer Opportunities I understand that submitting this application form does not guarantee a volunteer position, and that there are certain qualifications I must meet -- including the acceptance of established volunteer policies and procedures -- before I can begin volunteering. By submitting this form, I attest that the information I have provided on the form is true and accurate. I understand that if selected I must complete and/or provide the following before beginning my volunteer work: MCH Employee Health Requirements. TB Skin Test (provided by MCH Employee Health. Current immunization Record Background Check (completed by MCH Human Resources. Computer Based Learning Modules (to be completed after acceptance, but before June 6 start date. Will be sent by Human Resources).SignatureSignature of Parent (if applicant is under 18 years of age)NameThis field is for validation purposes and should be left unchanged.
