Volunteer Application Title ---Mr.Ms.Mrs.Miss. First name Last Name Date of Birth Address Line 1 Address Line 2 City State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Email Home Phone Work Phone Are you a full time resident of Florida? YesNo How did you hear about Halifax Health Volunteer Services? CRIMINAL BACKGROUND CHECKA criminal background check will be completed on all volunteers. This information will not necessarily disqualify you from consideration for voluntary membership in Halifax Health - Auxiliary. Have you ever been convicted of, entered a plea of guilty or no contest to, or had, adjudication withheld or entered into a pretrial intervention agreement with respect to any criminal offense? YesNo If yes, please provide details (including dates, state, and court involved). I Speak English and Availability in the Week Sunday MorningSunday AfternoonSunday EveningMonday MorningMonday AfternoonMonday EveningTuesday MorningTuesday AfternoonTuesday EveningWednesday MorningWednesday AfternoonWednesday EveningThursday MorningThursday AfternoonThursday EveningFriday MorningFriday AfternoonFriday EveningSaturday MorningSaturday AfternoonSaturday Evening I am willing to substitute YesNo I have the following physical or mental limitations Previous Work and/or Volunteer Experience Other Organizations that you are or were a member (indicate any offices held) Why are you interested in joining Halifax Health - Auxiliary? Are you interested in a particular service area? Do you have a particular experience or a skill set that may be an asset to Halifax Health? EMERGENCY MEDICAL INFORMATION: Primary Care Physician Physician's Phone Emergency Contact 1 Relationship to Emergency Contact 1 Cell Phone of Emergency Contact 1 Work Phone of Emergency Contact 1 Emergency Contact 2 Relationship to Emergency Contact 2 Cell Phone of Emergency Contact 2 Work Phone of Emergency Contact 2
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