Volunteer Services Application | Lucas County Health Center, Medical Center : Chariton, Iowa

Personal Information

Name:*

First Name Middle Initial Last Name Nickname

Address:*

Street Address City State ZIP Code

Home Phone:

Cell Phone:

Email:

Birthday:

Gender

Last 4 of SSN:

Highest Level of Education

Major or Degree (if applicable):

Student Section Only

Name of Current School:

Current Grade/Year in College:

Person to notify in case of emergency

Name:*

Fist Name Last Name

Address:*

Street Address City State ZIP Code

Home Phone:

Cell Phone:

Email:

Relationship:

Volunteer Preferences

How did you hear about our program?

Availability:

Where do you wish to volunteer?

LCHC Crafters Skills

Sewing
Crochet
Knitting
Crafts
Baking
Cooking
Card Making
Scrapbooking

LCHC Crafters Interests

Lap Blanket
Walker Caddy
Crochet Baby Cap
Knitted Baby Cap
Chemotherapy Turban
Birthday/Greeting Cards
Baby Blankets
Baking Cookies

Health Care Skills:

Other Skills:

I would be willing to:

Agreement

I understand and agree that submitting this application does not automatically enlist me as a volunteer at Lucas County Health Center. I understand and agree there may be policies I must agree to and qualifications I must meet before accepted. I also understand that there is no employer-employee relationship relative to my volunteerism and I will not receive monetary compensation in exchange.

Signature*

First Last

Parent/Guardian Signature

First Last

Date

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