Volunteer Application Name(Required) First Middle Last Email(Required) Enter Email Confirm Email Birth Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(If you are under the age of 18, you will need to fill out a Parental Consent Form) Sex(Required)FemaleMaleAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Phone Type(Required)Please Select OneHomeCellWorkWork Phone Yes, you can contact me on my work phone number. Employer Position Additional InformationThe information below is requested to help us better match volunteers to individual patients.Religion Language Skills Education Special interests, skills, hobbiesPrevious volunteer experienceExperience with ill or dying personsPrograms or ActivitiesPlease check all programs or activities you are interested in: Activity Aide CCCHD Auxiliary Clatsop Care Fresh Air Club Compassionate Companion Friendly Visitor Happy Hour Host / Hostess Meal Host / Hostess Munchies & A Movie Office Volunteer Pet Pals Reading Group Leader Room Décor & More Soothing Sounds Special Events Spiritual Services Visible Lives Storyboard Project Volunteer Barista Weekday Availability (Mon-Fri) Mornings Afternoons Evenings Nights Weekend Availability (Sat-Sun) Mornings Afternoons Evenings Nights How did you learn about volunteering at Clatsop Care Center? Ad / flier Walk-in Returning Friends / Family Other Other Interest in our programsPlease tell us about the reason for your interest in our programs. The more information and detail that you include, the better we will be able to make decisions about how to integrate you into the program. T.B. Screening Test(Required)To volunteer regularly at this facility you must consent to a T.B. screening test and a criminal background check. Do you consent to this? Yes, I consent No, I do not consent Emergency InformationAllergies and/or chronic health issues we should know aboutEmergency Contact Name(Required) First Last Emergency Contact Relationship Emergency Contact PhoneEmergency Contact Phone AlternatePhysician’s Name Physician’s Phone Δ
