McLaren Oakland - Online Volunteer Application Form

Date: *

Name (Last, First, Middle Initial): *

Address: *

City-State: *

Zip Code: *

Home or Cell Phone: *

In case of emergency, contact (include name, phone and relationship): *

E-mail Address: *

Gender: *

Birthday: Month - Day - Year: *

Are you 18 years of age or under? *

Name of High School

Graduated?

Graduation Year

Name of College:

Degree:

Graduation Year:

Name of Post Graduate School

Degree:

Graduation Year:

Are you a current college student?

Please list interests-hobbies:

I am interested in becoming a volunteer because?

I am interested in (check all that interest you) *

Referral Source *

Current Occupational Status *

What is volunteer level of volunteer commitment are you comfortable making*

Availability*

Employer and Position

Telephone Number

Date of Employment

Employer and Position

Telephone Number

Date of Employment

Personal Reference (and relationship) *

Phone Number *

Email Address *

Mailing Address *

Personal Reference (and relationship) *

Phone Number *

Email Address *

Mailing Address *

Personal Reference (and relationship) *

Phone Number *

Email Address *

Mailing Address *

Have you ever been convicted of a felony, or have any pending?

If yes, state charge, date, disposition:

I authorize McLaren Health Care and its affiliates or its designated agents to make whatever inquiries it may deem necessary in connection with my application for volunteer service. As part of such inquiries, McLaren has my permission to contact persons who may have information relating to my suitability to perform volunteer duties. *

 

Signature (Typing your name here indicates that all of the above information is accurate and acts as your electronic signature.) *