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Chelsea Community HospitalVolunteer ApplicationDate _____________Name ____________________________________________________Address ____________________________________________________City ____________________________________________________State ______________ Zip ______________Birthday ______________ Male ________ Female ____Telephone # ______________________Email address ______________________Last 4 digits of SSN _________________Volunteer AvailabilityWeekdays ________________ Weekends _____________A.M. ___________ P.M. _________Summer ___________ Winter _________Comments ___________________________________________________How did you learn about our Volunteer Opportunities?Friend/Relative _____ Newspaper _____ Brochure ______ Website _______Employee/Volunteer _____ Physician referral _____Other __________________________________________________________What areas are you interested in Volunteering in? (please circle as many as apply)Hospital Service AreaClerical Community Service Hospital ServicesPhone calls Blood Drive Information DeskComputer work Fairs Gift ShopReceptionist Special events Shuttle DriverFiling Senior services Mail DeliverySurgery Waiting ReceptionistPatient CarePatient Assist Liaison (P.A.L.)E.R. VolunteerEndo/Pain Clinic ReceptionistInfusion Center ReceptionistOutpatient PTOther interests ___________________________________________________________(over)

In case of emergency contact informationName ________________________________________________________________Relationship _________________________Address _______________________________City _____________________ State ________ Zip ___________Phone _____________________________Work/Volunteer informationPresent or Former (please circle one)Location _________________________________________________________Address _________________________________________________________City _____________________ State _________ Zip ___________Phone _________________________Your responsibilities ________________________________________________________________________________________________________________________Why do you want to Volunteer at Chelsea Community Hospital?Signature ______________________________ Date ______________OFFICE USE ONLYReceived ______________________________ Who? _____________Initial contact ______________________________ Who? _____________Interview/Orientation date __________________