Volunteer Form

Volunteer Application Form

Date:
Name:
Street Address:
City, State, ZIP:
Phone Number:
Alternate Phone:
Email Address:
Please indicate the type of volunteer work in which you are trained or have experience:
MD/DO DDS Dental Assistant Dental Hygienist Nurse Practitioner Physicians Assistant RN LPN Physical Therapist Medical Assistant Social Worker Lab Tech Nutritionist Dietician Counselor Secretary Medical Records Librarian; Pharmacist Pharmacy Tech Health Educator Other
If you are trained in a specialty of one of the above, please tell us what that specialty is (e.g. endodontist, Family Nurse Practitioner, etc.)
Please indicate the area or position in which you are interested:
The profession I indicated above Cleaning Crew Materials Management Building Maintenance Greeter/Escort Registering Patients/Appointments Publicity/Newsletter Dental Clinic Aide Spanish Interpreter Answering/Making Telephone Calls Gofer (I'll Do Anything) Computer Specialist Child Care (in Good Samaritan Building)
Other skills, experience and/or information that would be helpful to us:

We're not asking for a commitment at this time, but the following information will be helpful as we plan:
I estimate that I will be able to volunteer hours a week or hours a month.
What day(s) of the week are you most likely to be available to volunteer at Good Samaritan?
Monday Tuesday Wednesday Thursday Friday
Are you interested in contributing financially to Good Samaritan? Thank you for your generosity - it will make a difference! Once your donation is received, a letter acknowledging your gift will be sent to you. All donations are tax deductible. For questions regarding a donation to the Good Samaritan Health and Wellness Center, please call (706) 253-4673.