Last Name First Name Middle Initial Preferred Title -- Mr. Ms. Mrs. Other
If other, please specify
Date of birth
Mailing AddressCity State Zip
Home Cell Fax
E-mail
Preferred form of contact -- Home Work Cell E-mail
Your Physician's Name and/or Office Physician Phone #
Name & Relationship (i.e. friend, son, mother, etc.)
Emergency Contact Phone Number Alternate Phone Number
Do you have any limitations or special needs which need accommodations? -- Yes No If yes, please describe.
Have you ever volunteered at or been a Harrison employee? -- Yes No
If so, please list title and dates.Do you have family members employed at Harrison? -- Yes No If so, list location and department.
Current or previous work experience & dates.How long? List any special skills or hobbies.Referred by Do you have any previous volunteer experience? -- Yes No If so, please list organization and duties performed.
Please tell us what type of student you are? -- Junior High School High School College OtherIf other, please describe.
Will you be volunteering to: -- Meet requirments/credits General Experience
Where do you go to school?
List activities
Please check any areas that are of interest to you as a volunteer. Clerical/Administrative Clinical Support Gift Shop/Cashiering Harrison Foundation Events Patient Escort/Hospitality Projects OtherIf other, please tell us about your particular area of interest.
Please check which campus you prefer. Belfair Bremerton Port Orchard Poulsbo Silverdale
Availability (in most cases we ask for a six month commitment of at least one shift per week)
Indicate your intended time commitment as a Harrison volunteer.
One shirft (4 hours) Two shifts (4-8 hours) OtherIf other, please explain.
Indicate you general availability for volunteering at Harrison. Year-round Summer Only Event Only OtherIf other, please explain.
Indicate the day(s) of the week that work well for you. Monday Tuesday Wednesday Thursday Friday Saturday SundayPlease indicate the time(s) of the day that work well for you. (Please note available hours) Mornings Afternoons Evenings
Comments or Any Additional Information
Please list additional information you would like to share about your reasons for applying.The information provided on this application is true and complete to the best of my knowledge. I understand that my placement as an in-hospital volunteer is contingent upon acceptance by the Volunteer Resources Department based upon a personal interview and available position, satisfactory references and background check(s) for criminal history based upon the following as appropriate: a satisfactory National and/or WA State Patrol background check in accordance with all state and federal laws, a completed Child and Adult Abuse Disclosure Statement, and attendance at a Volunteer Orientation including completion and compliance forms and trainings. I understand I will not be paid for any volunteer services provided.
