*Indicates required information.

Personal Information
Format: 000-000-0000
Format: 000-000-0000
Volunteer Information
Volunteer Service Area Preferred
Availability

Volunteers are placed in a regular weekly assignment. Some volunteer assignments are available seven days a week, early morning through late evening. There are limited evening and weekend volunteer positions. Indicate the day(s) of the week you are available to volunteer. If you are flexible in the days/times you can volunteer, place a check in any of the boxes based on your availability. This information will help us determine the possible position openings that may be of interest to you.

Volunteer Shift Start Time

Contact 1
Format: 000-000-0000
Contact 2
Format: 000-000-0000
Please read and provide your digital signature

Medina Hospital is not obligated to provide a placement, nor are you obligated to accept the position offered. The Hospital also reserves the right to modify or eliminate the placement at any time for any reason, and you also may leave at any time. The offering of and/or placement in a position does not bestow any rights, privileges or benefits, employment or otherwise, upon you. My signature below affirms all the facts set forth in my application for volunteering are true and complete. I understand that if accepted, false statements, omissions or other misrepresentations by me on this application may result in immediate dismissal. I understand that I will be required to attend the hospital orientation and annual educational programs as required by Medina Hospital. I also understand and agree that in the performance of my duties as a volunteer of Medina Hospital I must hold in strictest confidence any observations I may make or hear regarding clients, client families or staff. I understand that intentional or involuntary violation of confidentiality may result in disciplinary action, including termination of volunteer services and/or possible legal action by others (i.e., clients, families of clients, etc.)