Volunteer Application First Name * Last Name * Birth Date * Address 1 * Address 2 City * State or Province * Please Select…AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutD.C.DelawareFloridaMicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriMarianasMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyomingMilitary AmericasMilitary Europe/ME/CanadaMilitary PacificAlbertaManitobaBritish ColumbiaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory Zip or Postal Code * Email Address * Mobile Phone * Primary Home Phone Are you a full time resident of Florida? * Yes No 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 any criminal offense? * Yes No Have you ever entered a plea of guilty or no contest to any criminal offense? * Yes No Have you ever entered into a pretrial intervention agreement to any criminal offense? * Yes No If yes to any of the above, please provide details (including dates, state, and court involved). Checkboxes * Sunday Morning Sunday Afternoon Sunday Evening Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Everning Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening Saturday Morning Saturday Afternoon Saturday Evening Languages * I am willing to substitute * Yes No 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 * Sign me up for future communitcations
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