Thank you for your interest in volunteering at Story Medical! Please review the disclaimer at right in full and complete this application for consideration.

Full Name (first, middle, last)

Address

City

State

ZIP Code

Home Phone

Cell Phone

Work Phone

Why are you interested in volunteering at Story Medical?

Other (from above)

Skills, interests and hobbies.

Do you speak any other languages? If so, please list.

Work and Volunteer Experience

Are you currently employed?

Yes

Retired

If employed, how many hours a week do you work?

Name of your employer

Have you ever been employed by or volunteered at Story Medical?

Yes

If yes, please list dates.

Have you ever been convicted of a crime in this state or any other state other than minor traffic violations?

Yes

If yes, please explain.

Do you have a record of founded child or dependent adult abuse in this state or any other state?

Yes

If yes, please explain.

Most Recent Work/Volunteer Experience

Organization

Title

Duties

Supervisor

Start/End Dates

Next Most Recent Work/Volunteer Experience

Organization

Title

Duties

Supervisor

Start/End Dates

Education and Training

Are you currently a student?

Yes

School

Year

Major

Are you available to work/volunteer during school breaks? (check all that apply)

Winter

Spring

Summer

None

Are you volunteering for a school requirement?

Yes

If yes, how many hours are required?

If yes, what class?

Name of School

Grade/Level Completed

Major/Degree

Availability

Please indicate which hours are best for you.

References

Reference 1 Name

Relationship

Years Known

Address

Phone Number

Reference 2 Name

Relationship

Years Known

Address

Phone

Areas of Interest

Check all that apply

Gift Shop Cashier - North Campus

Gift Shop Cashier - South Campus

Resident Visits at Senior Care (North Campus)

Senior Care Activities (Indicate Which Activities Below)

Senior Care Activities of Interest

Outings

Nail Painting

BINGO Assistance

Games

Submission

By typing your name in the box below, you are indicating you have read and understand the box at the right labeled "Disclaimer".

Volunteer Application

Work and Volunteer Experience

Most Recent Work/Volunteer Experience

Next Most Recent Work/Volunteer Experience

Education and Training

Availability

References

Areas of Interest

Submission