Volunteer at Kaiser Santa Rosa

Please select: *

Adult

Junior (15-18 years)

* denotes a required field

Name: *

Last, First, Middle

Address: *

Apt:

City: *

State: *

Zip: *

Home Phone: *

Other Phone:

Email Address:

Date of Birth: *

Day/Month

Presently Employed?: *

Yes

If 'Yes', Where?:

Educational and Volunteer Background: *

How Did You Learn About the Kaiser Permanente Volunteer Program?: *

Have You Ever Volunteered at any Kaiser Permanente Facility?: *

Yes

If 'Yes', Where and When?:

Have You Ever Been Employed by Kaiser Permanente?: *

Yes

If 'Yes', Where, When and in What Capacity?:

Why Are You Seeking to Volunteer?: *

Personal Commitment

School Program

Community Affiliations:

Skills, Interests and Hobbies: *

Emergency Contact Name: *

Emergency Contact Phone Number: *

Date of Birth For Junior Volunteers (15 - 18 Years):

School Attending (Junior Volunteers (15 - 18 Years) Only):

Signature

*Required Field* - By checking this box, you agree with the statement below:

I certify that all answers in this Volunteer application are true and correct, and have been given voluntarily.

*Required Field* - By checking this box, you agree with the statement below:

I understand that I am volunteering my services without contemplation of compensation or employment and given with humanitarian, religious or charitable reasons.

*Required Field* - By checking this box, you agree with the statement below:

I understand that the position of Volunteer requires that I be available to volunteer a minimum of four (4) hours per week for adults and two (2) for juniors for a minimum of one year.

*Required Field* - By checking this box, you agree with the statement below:

I understand 18 years of age and above will be required to have a background check.

Digital Signature: *

By typing my name in this box, I digitally sign this Volunteer application and verify that I am who I say I am.

Parent/Guardian Signature For Junior Volunteers:

By typing my name in this box, I digitally sign this Volunteer application and verify that I am the parent/guardian of the junior applicant and I give permission for the junior applicant to apply as a Volunteer for Kaiser Permanente.

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Volunteer at Kaiser Santa Rosa

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