Current Security level:

I am interested in volunteering at St. Mary's Good Samaritan (please select a location): 400 N. Pleasant - Centralia 605 N. 12th - Mt. Vernon
PERSONAL DATA *required
*Name (First & Last):
*Address:
*City:
*State:	- - AL AR AZ CA CO CT DC DE FL GA IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
*Zip Code:
*Phone:
E-mail address:
Emergency Contact:
Address:
City:
State:	- - AL AR AZ CA CO CT DC DE FL GA IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:
Phone:
Are you a minor (age 15 to 17)?	Yes No (If so, a parent signature will be required if accepted into the volunteer program.)
Name of employer (if applicable)
How did you become interested in our volunteer program?
Have you been a member of our volunteer program in the past?	Yes No
If yes, when were you a member? (Enter Date)	Start: (Click for Calendar) End: (Click for Calendar)
EDUCATION
If you are currently attending school, please list the name of the school:
Highest grade completed:
Career Interest:
Are you presently employed?	Yes No
Work Experience:
Volunteer Experience:
Membership in other Community Organizations:
Personal or Professional References (please exclude relatives)
*1. Name:
Address:
City:
State:	- - AL AR AZ CA CO CT DC DE FL GA IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:
Phone:
*2. Name:
Address:
City:
State:	- - AL AR AZ CA CO CT DC DE FL GA IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:
Phone:
Availability
*Days preferred: (Please check all that apply)	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
*Hours preferred:
Date available to begin volunteering:	Start: (Click for Calendar)
How often would you like to volunteer?	Weekly Monthly
How many hours?
*Length of Commitment	Less than 3 months 3-6 months 1 year plus
VOLUNTEER INTERESTS
Reasons for volunteering:
Please check one or more of your preferences	Volunteer Opportunities in Mt. Vernon: Admitting Bargain Box Outpatient Surgery E.R. (Emergency) I.C.U. (Intensive Care) Patient Care Services Plant Facilities Education Library Gift Shop Information Desk Menu Distribution Home Health/Hospice Other (please specify) Volunteer Opportunities in Centralia: Admitting Patient Escort Waiting Room Reception Gift Shop Gift Cart Information Desk Other (please specify)
Skills
Please check all that apply.
Clerical:	Answering phone Computer Skills Copying Filing Operating cash register Organizing books Other (please specify) Processing mailings Typing Updating records
Communication:	Calligraphy Foreign language Graphic design Public speaking Researching Sign language
Patient Care:	Escort patients Transport patients Read to patients Visit with patients
Personal skills you are willing to share or teach:	Knitting Crocheting Sewing Crafts Needlework Musical instrument (please specify) Other (please specify) Instrument: Other:
* The information submitted in this application is accurate to the best of my knowledge.	Yes No By checking "yes", you give us permission to check your references. Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, or sex. The organization is not obligated to provide a placement, nor are you obligated to accept the position offered.