Pomona Valley Hospital Medical Center
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Junior Volunteer Application Request
Thank you for your interest in the Volunteer Program at Pomona Valley Hospital Medical Center (PVHMC). Please fill in this webform to submit your application request.
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User ID/e-mail address
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User ID/e-mail address confirm
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Password
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Password confirm
Junior Volunteer Application
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First name
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Family/last name
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E-mail
Home phone Number
Cell Phone Number
School Currently Attending
Graduation Year
Are you related to a PVHMC Associate?
Yes
No
If yes, Associate Name
Relationship
Why do you want to volunteer at PVHMC?
What do you hope to learn as a result of volunteering at PVHMC?
How do you feel that you can best benefit PVHMC as a Volunteer?
What days will you be available to volunteer?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Additional Information
Birthdate
Address Line 1
Line 2
City
State
Zip/postal
Parent/Guardian Name
Cell Phone Number
Work Phone Number
Do you share a primary residence with this person?
Yes
No
Secondary Emergency Contact Name
Cell Phone Number
Work phone
Do you share a primary residence with this person?
Yes
No
Have you had the Chicken Pox?
Yes
No
Do you have a known allergy to latex?
Yes
No
Do you have any physical limitations to be considered for volunteer placement?
Yes
No
If yes, please explain.
Do you require any special accommodations?
Yes
No
If yes, please describe.
How did you hear about our program?
Background Information
Are you obligated to fulfill court ordered community service?
Yes
No
If yes, please give a description of your offense, number of hours, date of court order, and required date of completion.
Have you ever been arrested or convicted of a criminal offense (misdemeanor or felony)?
Yes
No
If yes, please give date, place of conviction, and explain circumstances. Please be aware that a criminal record does not automatically disqualify you from volunteer work at PVHMC.
Do you have any criminal charges pending against you which are unresolved?
Yes
No
If yes, please explain.
Please allow up to two weeks for processing of your request. You will receive an e-mail within that time either granting your request to continue the application process or denying it. We select those who will continue with the process based on the answers given above. Not all requests will be accepted.
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