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Helen Keller Hospital

HKH Volunteer Application

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.
* Application Date
MM/DD/YYYY
* First Name
  Middle Initial
* Last Name
  Preferred Name
  Birthdate
MM/DD/YYYY
* Social Security Number
* Address (City, State, Zip)
* Home Phone
  Additional Phone (Cell, etc.)
  Highest level of education
  Do you need any special accommodations to serve as a volunteer?
  Are there any hours that you cannot work or do you have preferences about the hours that you can work?
First Reference
* Name
* Phone
  Relationship
Second Reference
* Name
* Phone
  Relationship
  Is there any particular area of the hospital that you are interested in working?
  How old are you?
  Have you ever been convicted of a felony or misdemeanor?