UMMC Volunteer Application Form

Must be 16 years of age or older to apply.

Please allow two weeks for application processing.

* - Required Fields

First Name*	*
Middle Initial
Last Name*	*
Maiden Name
Preferred Name
Date of Birth*	*Invalid Date
Sex*	Female Male *
Address*	*
City, State, Zip Code*	* AK AL AR AZ CA CO CT DC DE FL GA HI 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 * - ***
Email*	*Invalid Email
Home Phone*	() - ******
Mobile Phone	() - ext.***
Emergency Contact(s)
Relationship to Volunteer*	*
Last Name*	*
First Name*	*
Street Address*	*
City, State, Zip Code*	* AK AL AR AZ CA CO CT DC DE FL GA HI 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 * - ***
Home Phone*	() - ******
Mobile Phone	() - ext.***
References (No relatives)
Name*	*
Email*	*Invalid Email
Phone Number*	() - ******
Name*	*
Email*	*Invalid Email
Phone Number*	() - ******
Volunteer Assignment Preferred*	Children's Hospital Adult Hospital Spiritual Care *
Days and Hours Available*	*
Click to read the The UMMC Information Systems Security Acknowledgement and Nondisclosure Agreement.*	I have read the Information Systems Security Acknowledgement and Nondisclosure Agreement. *
As a volunteer of UMMC, I agree to the above reference checks, TB skin tests and a background check.
Volunteer Signature*	*
Parent or Guardian signature for volunteers under 18. If you are under 18, a parent must be present for your fingerprinting and TB skin tests.
After submitting the application form, please read and sign the Volunteer Agreement (link located in the menu to the left).