AHTM Teen Volunteer Registration Form

Volunteer Availability & Placement

Please select all days and times you are available to work.
Volunteer services you are interested in (check all that apply):

In-HospitalHospiceWellspring Respite Day Center
Are you able to push a wheelchair?

YesNo
Are you able to be on your feet for four hours?

YesNo
Please list volunteer and paid work you have done.
Can you write or speak a foreign language?

YesNo
What languages?
Interests, hobbies or special talents:

References

Please list two references. DO NOT include physicians or relatives.
Reference 1

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In an emergency please notify:
Full Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Physician
Phone
Please list any allergies you have:
The information provided in this application is true in all respects without any willful omissions.

Check here if true
NOTE: For teens under age 18 years, a parent/guardian signature is required to complete this application. You will be given a signature form by the Adventist Health Tillamook Volunteer Services office.
Should be Empty:

Teen Application