*Indicates required information.

Personal Information
Format: 000-000-0000
Person to be notified in case of accident or illness
Volunteer Information
Volunteer Service Area Preferred
Availability

Volunteers are scheduled one day a week for a four hour shift of either 8 am-12 pm, 12-4 pm or 4-8 pm. Please note any days and shifts you would be available for volunteering.

A conviction will not automatically disqualify an applicant. The nature of the crime, the date of the conviction, and other pertinent details may be considered.)
Contact 1

Please list a school guidance counselor and an adult (please do not include relatives) we may contact for a reference:

Format: 000-000-0000
Contact 2

Please list a school guidance counselor and an adult (please do not include relatives) we may contact for a reference:

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.)