Volunteer Application

Our Response to COVID-19

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If you wish to volunteer, please fill out the forms below and email them to stmarysvolunteermanager@uhsinc.com.

Practitioner Disclosure

Practitioner Information

Precheck Release

Are you an adult? (Age 18 or over) *

Yes

Name (Last) *

Name (First) *

Address *

City *

ZIP *

Email *

Home phone *

Cell phone *

Birthdate *

Work Experience *

Volunteer experience (list places and dates of service): *

Education/special training completed *

School

Hobbies, skills, interests *

Reason for wanting to volunteer *

Timeframe you would like to volunteer *

Note: St. Mary's is unable to offer volunteer opportunities to people seeking short-term service or community service hours.

Select the areas where you may be interested in serving *

List the time/s you would prefer to volunteer each week: *

Shifts are available every weekday from 8 a.m. to Noon and Noon to 4 p.m.

Do you have available transportation? Yes/No *

Yes

Have you ever committed a crime? If yes, explain.

Note: Conviction does not necessarily disqualify applicant.

Person who referred you to St. Mary's Volunteers

Personal reference

Name *

Phone Number *

Emergency contact person

Name *

Relationship *

Home phone *

Cell phone *

Physician

Name

Phone number

I understand and agree that:

Each time I volunteer, I will wear the appropriate uniform for my service area and my badge. As a volunteer, I will keep all information about patients confidential. I will be reliable and fulfill my service commitment. I understand that if I should misrepresent or deliberately leave out a fact in my application, I may be refused the opportunity to volunteer or may be terminated from the volunteer program.

Signature: *

Date *

Year

Month

Day

Our Response to COVID-19

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Volunteer Application

If you wish to volunteer, please fill out the forms below and email them to stmarysvolunteermanager@uhsinc.com.