Online Application

APPLICATION FOR VOLUNTEER SERVICES

Please check desired location:	Volunteer Classification:
Upper Chesapeake Medical Center	Junior (Age 15-17) must be at least 15 years of age OR have completed the 9th grade.
Harford Memorial Hospital	Senior (Age 18 and over)

First Name:

Last Name:

MI:

Street:

City:

State:

Zip:

Home Phone:

Work Phone:

Date of Birth:

Are you currently attending school? Yes No

If yes:

Name of School:

Highest Grade Completed:

Do you speak another language, if yes, please list:

Occupation or professional training (current or previous):

Other skills not previously addressed:

List previous volunteer experience:

How did you learn about our program?

Health Record
Date of last MMR (Measles, Mumps, Rubella) Vaccination: If you were born after 1957, Please include a copy of the record.
Date of last TB Skin Test:
Do you have any physical or mental limitations that would affect your placement as a volunteer?
	No
	Yes, please explain:

Person to be notified in case of an emergency:
Name:
Relationship:
Phone:

I hereby certify that the answers and explanation to all the preceding questions are true and complete to the best of my knowledge.
Name:
Date:

	Upcoming Foundation Events
	Family BirthPlace Entrance Relocated
	UPCOMING RECRUITMENT EVENTS

	About HealthLink
	HealthLink Today (.PDF)
	Classes, Screenings, Support Groups
	Online Health Information

(See Notice of Privacy Protection Under Hospitals)