*Indicates required information. Personal Information First nameLast nameMiddle initialSuffixStreet addressStreet address 2CityZip CodePhone numberFormat: 000-000-0000E-mail addressHave you ever been an employee or volunteer of Medina Hospital? Yes No Date/s you were an employee or volunteer at Medina Hospital Emergency Contact NameEmergency Contact Phone NumberFormat: 000-000-0000Relationship to emergency contact Volunteer Information Previous Volunteer Experience Are you related to anyone at Medina Hospital? Yes No If yes, what department do they work in? Volunteer Service Area Preferred Choice 1Choice 2Choice 3 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 Day of the week Monday Tuesday Wednesday Thursday Friday Saturday Sunday Shift 8 a.m. - 12 p.m. 12 - 4 p.m. 4 - 8 p.m. Who referred you to Medina Hospital to volunteer? Friend/Relative Media/Ads Employee Physician My preferred hospital Other Have you ever been convicted of a felony? Yes No If so, please explain. Contact 1 First NameLast NamePhone NumberFormat: 000-000-0000RelationshipCityState Outside of USA Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Idaho Iowa Illinois Indiana Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip CodeStreet Address Contact 2 First NameLast NamePhone NumberFormat: 000-000-0000RelationshipCityState Outside of USA Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Idaho Iowa Illinois Indiana Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip CodeStreet Address 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.) Digital SignatureDate