Name:

Address:

Phone Number: 

                               (including area code)

Work Experience:

Volunteer Experience:

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I am interested in the:

Teen Program   (Age 14, completed the 8th grade)

       Auxiliary Membership Dues $2.00

Adult Program   (Senior in High School or out of school)

       Auxiliary General Membership Dues $5.00

       Auxiliary Lifetime Membership Dues $100.00

 

(Acceptance of this application does not obligate Camden-Clark Memorial Hospital to offer you a position as a volunteer, nor does it obligate you to accept a position if offered)

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 References:  Please list two, not relatives. Only references with full mailing addresses will be accepted.

 1. Name:     

    Address:

 

 

 2. Name:      

    Address: 

 

 I AUTHORIZE CCMH TO OBTAIN REFERENCES FROM THOSE PROVIDED ABOVE.

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   **  The entry of my name and e-mail address below constitutes applying my signature to this application for electronic submission. **

 

 Name:      

 E-mail: 

 Date: