Volunteer Registration Form

Last Name:     First Name:     MI:

Home Phone:      Work Phone:        Cell Phone:

Address:   City:   State:   Zip:

Email:  

Are you currently?        Employed      Unemployed      Retired

If employed, what city?

What days or hours would you be most available?

Secondary Contact information:

Please list another contact person, phone number or pager number that we could use to contact you if we can't reach you by the numbers listed above:

Person:   Phone Number:   Pager Number:

Would you be willing to volunteer in another county?    Yes     No 

If yes, please list county or counties you would be interested in volunteering in:

Would you have child care needs?  Yes     No 

Which of the following volunteer positions best suit your abilities?  (Please check all that apply)

      RN                                               LPN                                      Medical Staff

      Security                                        Traffic Control                        Mental Health

      Data Entry                                    Supply Clerk                           Translator

      Custodial                                      Float Staff                             Special Needs

      Registration                                  Food Service                          Pharmacy

      Office Help                                   Management Information (MIS) 

If you selected Medical Staff, please list certification/licensure:

If you have any questions, please call our office at 304-272-6761.

When you have finished reviewing your form, please click on the submit button below.  Thank you for your desire to help your community.