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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:
Name:
Name of Parent or Guardian:
(You will be required to have their permission to participate)
Cell Phone of Parent:
Birth Date:
(A Junior Volunteer must be 13 years of age or 13 before June 30 to participate in the summer program)
Age, Grade and School:
School Guidance Director:
Mailing address:
E-mail address:
Phone number(s):  
Previous volunteer experiences, if any. No previous experience required!  
Special training or interests:  
Medical Conditions:
Do you have any medical conditions or learning disabilities that we should take into consideration when assigning tasks, to make your volunteer experiences at Mid Coast Hospital more productive?
 
Medications:
Do you take any medications regularly which should be known in an emergency situation? If yes, what are they?
 
   
Tell us what you would like:
Availability - How many hours a week can you volunteer and what days are best for you?
Why are you interested in becoming a junior volunteer at Mid Coast Hospital?
Personal Reference #1:
Name:
Address:
Phone number:
How does this person know you?
Personal Reference #2:
Name:
Address:
Phone number:
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. You can view the forms here: Confidentiality, Parental Permission and Authorization for Release of Information.
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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