Calais Regional Hospital - Volunteer Application
|Last Name||First Name||Middle Name||Social Security Number|
Position You Are Volunteering For:
Are You Willing to Be:
Approximate Hours Available:
Have you ever had or been told that you had:
|a.||Dizziness, fainting spells, epilepsy, severe headaches, stroke, or any disease or disorder of the brain or nervous system?|
|b.||High blood pressure, chest pain, shortness of breath, heart trouble, stroke, swelling of the legs or ankles, or rheumatic fever?|
|c.||Back injury, back sprain or strain, or another condition of the spine?|
Have you ever been treated for nervousness, nervous breakdown, emotional illness, or alcohol or drug abuse?
Please give us some information about yourself. What are your interests? Why are you interested in volunteering at the hospital? Do you have specific ideas about how you would like to spend your volunteer time? What are they? We want to get to know more about you. (Optional)
I hereby certify that all statements and answers I have provided are complete and true.