2. Name *
  3. Address *
  4. City *
  5. State *
  6. Zip *
  7. Home Phone
  8. Work Phone
  9. Cell Phone
  10. Email *
  11. Confirm Email *
  12. Date of birth *
  13. Separator
  15. Name *
  16. Relationship *
  17. Phone *
  18. Name *
  19. Relationship *
  20. Phone *
  21. Separator
  23. Shifts
  24. Days *
  25. Separator
  27. Check Box
  29. Check Box
  30. Separator
  32. Name *
  33. Phone *
  34. Name *
  35. Phone *
  36. Name *
  37. Phone *
  38. Separator
  40. Text Box
  41. Text Box
  42. Separator
  44. Text Box
  45. Separator
  47. Text Box
  48. Separator
  50. Have you ever been convicted of a Felony?
  51. Convicted Date (if applicable)
  52. Separator
  54. Comapny or School
  55. Position
  56. Address
  57. Phone
  58. Hours of Work
  59. May we contact
  61. Check Box
  62. Recaptcha Google Panel
  63. Submit

Contact Information

Emergency Contact

Availability

During which hours are you available for volunteer assignments? (Evening and Sat/Sun shifts are only for gift shop)

Interests

Tell us in which areas you are interested in volunteering

Which location are you interested in?

References

List 3 Persons (Other than Relatives)

Volunteer Information

Special Skills or Qualification

Previous Volunteer Experience

History

Current Employment/School

Disclaimer and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

I understand that Mercy Hospitals of Bakersfield reserves the right to not accept all applicants or to terminate a volunteer if performance standard is not in compliance with The Joint Commission and State of California Standards for volunteer service. A performance evaluation will be completed on all volunteers assigned to Mercy Hospitals of Bakersfield. It is further understood that before I begin a volunteer assignment, I must first complete the Hospital Required Medical Tests and Orientation Training.