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Junior Volunteer Online Application

Please review the application process before filling out this form.
You may also print out the application in PDF format. (Mailing address is in the pdf. If you are 16 or older, you will also need this form: Authorization for Release of Information.)

Note: All fields required        
Please tell us about you:
Full Name:
Phone:
Birth Date:
(To participate in this program you must be 13 years of age before June 30)
Age, Grade and School:
Street address:
City/State/Zip:
Gender:
E-mail address:
Medical Conditions:
List any medical conditions or learning disabilities that we should take into consideration when assigning you tasks.
 
Medications:
Do you take any medications which should be known in an emergency situation?
If yes, what are they?
   
   
Volunteering:
Special training or interests:  
Previous volunteer experience:  
Why are you interested in becoming a junior volunteer at Mid Coast Hospital?
Personal References:
School Guidance Counselor:
Phone:
Personal Reference:
(No family members)

Phone:
How does this person know you?
   
You will also need to complete Confidentiality and Parental Permission forms at the hospital before final approval of your application. If you are 16 or older, you will need to complete an Authorization for Release of Information form as well.  
Click button below to move to the second and final step.


 

 
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Mid Coast Hospital - For a Lifetime of Caring

123 Medical Center Drive, Brunswick, Maine 04011
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Accredited by The Joint Commission. Recognized as
a Magnet™ Hospital for exceptional nursing and patient care by the American Nurses Credentialing Center.
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