Junior Volunteer Application

Name
Address
Phone
email
Birthday (day/month)
Present age
Parent/Guardian
Name and phone
In an emergency when parents or guardians cannot be reached notify
Education
Name of school
Years completed	6th grade    7th grade    8th grade    9th grade    10th grade    11th grade    12th grade
Work Experience
Skills or Hobbies
Volunteer experience or training
I want to volunteer	Summers    School year    Year round
List areas of interest
Indicate days and times when available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total hours available per week
Will you be in a carpool with another Junior volunteer or staff person?
	yes    no
If so, who?
How did you learn about our volunteer program?
Tell us why you want to be a volunteer
Have you ever been convicted of a misdmeanor or a felony in the past seven years?
	no yes
If yes please explain
I affirm that the information I have provided in this application form is true and correct to the best of my knowledge. I understand that misrepresentation, omission or falsification of facts in connection with this information may be sufficient cause for cancellation of consideration for volunteer service or termination whenever discovered.
	yes no
I understand that as a condition of participation in this program, that I may be required to provide the following: A completed State of Minnesota Criminal Background Study form or Criminal Bureau of Apprehension form, a Mantoux test, reference checks, Failure to cooperate or unsatisfactory results may result in withdrawal of an offer to participate in this volunteer program. As a condition of participation in this volunteer program, I hereby authorize HealthPartners/Regions Hospital volunteer Services to conduct an inquiry into any service-related information contained in this application.
	yes no

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