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Volunteer/Student/Intern Application

Thank you for your interest in becoming a Bay Medical Volunteer. Please complete the information below.

Please indicate the type of volunteer position
you are applying for:
*
Last Name:*
First Name:*
Middle Name:
Address Street:*
City:*
State:*
Zip:*
Phone:*
Email:*
Date of Birth:*
(MM/DD/YYYY)
In Case of Emergency, notify:*
Emergency Contact Phone:*

Experience

Work/Professional:
Volunteer:
Education/Special Training:

When are you available to volunteer?

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

Restrictions

Do you have any medical problems which would limit your abilities to perform your duties as a volunteer/intern?*
 yes no
If yes, please explain so that we are able to make a better placement for you.:

Background Information

Have you ever been convicted of a felony?*
 yes no
If yes, please explain briefly:

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!