Required fields are marked with an asterisk *. Applicant informationFirst Name *Middle Name *Last Name *Address *City *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip *Home PhoneCell PhoneE-mailBest time to contact you:Are you at least 18 years of age?YesNoBirth date (Month/Day)In case of emergency, please notify:NameRelationshipDaytime phone number(s)Education and experienceFormal education or trainingCurrently or plan to be a student in college/nursing program?YesNoWhat school?Professional certificationCurrent employer and addressSupervisor nameEmployer phonePrevious occupationsHave you ever been convicted of a crime?YesNoIf yes, please explain when, where, and dispositionI have volunteered at Centerpoint, Independence Regional, or Medical Center of Independence previously:YesNoWhy do you want to volunteer?Previous volunteer experience:OrganizationSupervisorType of service performedDateAddress and phone numberOrganizationSupervisorType of service performedDateAddress and phone numberHave you ever been terminated from employment or volunteer service?YesNoIf yes, please explain:ReferencesNamePhoneAddressNamePhoneAddressNamePhoneAddressAvailable time for volunteering (please check all time that apply) Sunday Morning Sunday Afternoon Sunday Evening Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening Saturday Morning Saturday Afternoon Saturday EveningApplicant acknowledgment: I certify that the information given by me in this application is trueand complete. I hereby authorize all individuals and organizations named or referred to in thisapplication to give Lakeview Regional Medical Center all information relative to my possible volunteerassignment and work habits. I hereby release such individuals, organizations and Lakeview RegionalMedical Center from any liability for any claim, damage, which may result. I understand that Iwill not be paid for time volunteering at Lakeview Regional. Rate Your Experience Submit SuccessThe form was successfully sent. There was an error with the form submission.