Harnett Health Junior Volunteer Application

Harnett Health Junior Volunteer Application

Must be 16 years old to apply
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Grade Level*

9th10th11th12th
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than Home Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship*
Parent/Guardian Information
Parent/Guardian #1*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Parent/Guardian #2*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Current School*
Have you ever been suspended from school?*

YesNo
How did you hear about the Junior Volunteer Program?*
Do you have any relatives or close acquaintances at Harnett Health?*

YesNo
List names and relationships*
Preferences - Location*

Cape Fear Valley Betsy Johnson HospitalCape Fear Valley Central Harnett Hospital
Preferences - Days*

Type option 1Type option 2Type option 3Type option 4
Preferences - Shifts*

Type option 1Type option 2Type option 3Type option 4
Number of hours available each week*
Why do you want to volunteer with Harnett Health?*
Personal references

(other than relatives)
Teacher Information*

First NameLast Name
Email*
example@example.com
2nd Reference*

First NameLast Name
Email*
example@example.com
Harnett Health System is an Equal Opportunity/Affirmative Action Employer. All decisions to accept individuals as volunteers are based on individual qualifications without regard to race, color, sex, national origin, age, religious belief, or disability.

I pledge that all information stated on this application is true to the best of my knowledge.
Applicant Name*

First NameLast Name
Applicant Signature*

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I have read my child’s completed application and concur that the information is accurate as stated. They have my permission and support in volunteering with the Harnett Health Junior Volunteer Program, if selected.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

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Harnett Health Junior Volunteer Application

Parent/Guardian Information

Personal references