Ellsworth County Medical Center : Volunteer Application

Volunteer Application
Thank you so much for your interest in volunteering for Ellsworth County Medical Center (ECMC). To ensure that you are provided the best experience possible and to appropriately communicate with you, please complete the following questionnaire.

	First Name
	M.I.
	Last Name
	Home Phone Number
	Cell Phone Number
	Current Mailing Address
	Are you under 18 years old? Note: you must be at least 15 years old to volunteer at ECMC.
	E-Mail Address
	Name of High School
	School Address
	School Phone
	Name of Guidance Counselor
	Grade Level
	How did you learn of the volunteer program at ECMC?	ECMC Health Matters Magazine ECMC Staff Member Newspaper Article
	Other
	Please indicate all days and times you are generally available to volunteer
	Mondays
	Tuesdays
	Wednesdays
	Thursdays
	Fridays
	Saturdays
	Sundays
	Please list skills that you have and would be willing to utilize	Drawing Arts & Crafts Reading Computer Video Games Cards Sewing / Kniting Pampering (hairdo’s nails etc.) Music (instrument/vocal)
	Have you previously been a volunteer anywhere? Please list.
	What do you believe you will bring to this Volunteer Position?
	ECMC will offer a Volunteer Orientation which will include a Health Screening (ppd/tuberculosis) test which will be provided by the hospital. If under 18 years of age, a parent / guardian must sign the following consent. I certify the statements made in this application are true and correct, and have been given voluntarily. I understand this information may be disclosed to and party with legal and proper interest. I agree and have marked the correct statements below that apply to me. I understand that this is a volunteer program, and I must attend Orientation, Health Screening and complete all necessary documents to participate.
*	I am NOT required by court to perform voluntee r or community service.
*	I understand I will be required to comply with the volunteer dress code.
*	I understand I will be required to comply with ECMC cell phone policies.
*	Electronic Signature
*	Date