(ATTACHMENT 1) LAKEVIEW HEALTH CENTER VOLUNTEER INFORMATION SHEET NAME

(ATTACHMENT 1) LAKEVIEW HEALTH CENTER VOLUNTEER INFORMATION SHEET NAME
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VOLUNTEER OPPORTUNITIES (ATTACHMENT 7) LAKEVIEW HEALTH CENTER PLEASE CIRCLE

Lakeview Health Center

(Attachment #1)

Lakeview Health Center


VOLUNTEER INFORMATION SHEET


Name: ______________________________________________________ Date of Birth: __________________

Last First Middle


Address: ________________________ City: __________________ State: _________ Zip Code: __________

Phone: __________________ Cell Phone: _________________ E-Mail Address: ________________________


Any past history of theft or abuse? Yes: ______ No: ______



In Case of an Emergency, Contact:


_________________________________________________________________________________________

Name Phone


Previous Work/Volunteer Experience:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


STUDENTS: Please Indicate Number of Required Volunteer Hours if Needed:

__________________________________________________________________________________________


School Name: ____________________________ Area of Study: _____________________________________


Special Education, Skills, Training, or Interests which you feel would be relevant to working with Lakeview Health Center Residents:

____________________________________________________________________________________________________________________________________________________________________________________


Availability: (please mark days and times available)


Mon ________ Tues _________ Wed _________ Thurs ________ Fri _________ Sat _______ Sun _________


How many hours a week would you like to volunteer? ______________________


Personal References: (please use local references and do not use relatives)


Name: ______________________ Phone Number: ___________________ Occupation: __________________

Name: _______________________Phone Number: ___________________ Occupation: __________________


AS A VOLUNTEER, I WILL ENDEAVOR TO BE PROMPT AND CONSISTENT IN MY VOLUNTEER SERVICE AND I WILL OBSERVE ALL FACILITY REGULATIONS.



SIGNATURE: ____________________________________________ DATE: __________________________





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