Personal Information * Required Fields What facility are you applying for? * Autumn View Health Care FacilityBrookhaven Health Care FacilityGarden Gate Health Care FacilityHarris Hill Nursing FacilityNorthgate Health Care FacilitySeneca Health Care CenterJourneys Program Name * Address * City * State * Zip * Home Phone * Cell Phone Work Phone Email Are you less than 18 years of age? YesNo If yes, how old are you? List your particular interests, skills, and hobbies: Volunteer Experience Volunteer Location Start Date End Date Address Phone What did you do as a volunteer there? Do you have any disabilities that would hinder your performance in the volunteer position for which you are applying? YesNo If so, what reasonable accommodations may be made to enable you to perform the duties of the volunteer positions? Availability Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times not available Hours available per week Hours available per month Employment/Education Where do you currently work/study? How many hr/wk? If student, number of hours needed to complete requirements for school/course credit? Course Title Name of Teacher Services you would be willing to help us with Why do you want to volunteer? Anything else you would like to tell us about yourself that would help us evaluate the best place to use your talents? How did you find out about our facilities? Photographic/Model Release. I give The McGuire Group, Inc. and all of its facilities the permission and rights to copyright and/or use or publish photographic or illustrative photographs of me in which I may be included in whole or part. There is no limitation as to its use - whether I am a part of the corporation or not. Emergency Contact Name Relationship Address City State Zip Home Phone Cell Phone Work Phone Email I hereby sign that all the above information is true and accurate. Any false information will result in termination of my volunteer services. By checking this box, I agree to submit this application electronically and understand that an electronic signature has the same legal status and can be enforced in the same way as a written signature Electronic signature * Date*
