Bay Medical - Bay Medical

Please indicate the type of volunteer position
you are applying for: *

Last Name: *

First Name: *

Middle Name:

Present Address:

Telephone No: *

Email:

Birth Date: *

In case of emergency, notify: *

Phone:*

Experience:

Work/professional:

Volunteer:

Education/special training:

When are you available to volunteer?:

Days:

MondayTuesdayWednesday ThursdayFriday
Saturday Sunday

Times:

8-1212-44-8

Please select the areas in which you are interested in volunteering:

Patient RelationsGift Shop
Clerical AreasMagazine Delivery
Uniform ShopSurgical Waiting Room
Information DeskICU Waiting Room
Outpatient CenterEmergency Dept.
Patient RegistrationSurgical Recovery Area

Restrictions

Do you have any medical problems which would limit your abilities to perform your duties as a volunteer/intern? *

YesNo

Background Information

Have you ever been convicted of a felony? *

YesNo

(An official background check will be conducted.)

Please list two personal references

Reference 1

Name: *

Phone: *

Reference 2

Name: *

Phone: *

How did you hear about the Volunteer Program?

* I understand that I am applying to become a volunteer/intern at Bay Medical, not an employee. By signing this application I am acknowledging that all information on this application is true and correct. I also agree to treat all patient and hospital information as confidential and will not discuss the condition of patients or any other information obtained by volunteering/interning at Bay Medical. I understand that breach of this agreement will result in permanent removal from the program.

We look forward to having you on our team!