Salem Regional Medical Center – Volunteer Services

Volunteer Application

Name
Address / Home Phone
(City, State, Zip) / Cell Phone
Occupation / Email
Spouse / Employer
DOB
Emergency Contact
Name / Phone Number
Address / Relation
(City, State, Zip)
Availability
Monday / Tuesday / Wednesday / Thursday / Friday
5 am – 9 am / 5 am – 9 am / 5 am – 9 am / 5 am – 9 am / 5 am – 9 am
8 am – 12 pm / 8 am – 12 pm / 8 am – 12 pm / 8 am – 12 pm / 8 am – 12 pm
12 pm – 4 pm / 12 pm – 4 pm / 12 pm – 4 pm / 12 pm – 4 pm / 12 pm – 4 pm
4 pm – 8 pm / 4 pm – 8 pm / 4 pm – 8 pm / 4 pm – 8 pm / 4 pm – 8 pm
Volunteer Experience
References / References Must Be Non-Family Members
Reference 1 / Relationship / Phone
Reference 2 / Relationship / Phone
Reference 3 / Relationship / Phone

Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?

Yes / No / If yes, please explain:

All regular volunteers must agree to submit to a minimum of 40 hours of volunteer work per year. Do you agree to work a total of at least 40 hours of volunteer work?

Yes / No

Are you required by a school or other work institution to complete a certain number of volunteer hours?

Yes / No

If so, please list the organization name, program name, teacher or supervisor, number of hours required, and any special requirements needed.

Organization / Program / Hours
Supervisor / Special Requirements

Volunteers must submit to a background check before admittance into the hospital. Volunteers under 18 years of age must have a parent or guardian sign a release form. Are you 18 years or older?

Yes / No

Are you Bilingual? If so, please list languages:

Yes / No / Languages:
Medical History
Pertinent Medical History
Family Doctor

Are there any limitations we should be aware of physically or in terms of scheduling?

Limitations