Volunteer Services Application

Personal Information

* First Name

Middle Name

* Last Name

* Date of Birth

Gender

Current Address:

* Street

* City

State

* Zip Code

Telephone Number(s) with area code:

Day

Evening

* Cell

* E-mail address:

Parental Information

* Parent/Guardian Name (First and Last)

* Parent/Guardian E-mail

* Parent/Guardian Cell

Emergency Contacts

* Name:

* Relationship to you:

Telephone Number:

* Cellular Number:

Physician's Name:

Hospital Affiliation:

Physician's Telephone Number:

Volunteer Service Information

Availability

Sunday Morning

Sunday Afternoon

Monday Morning

Monday Afternoon

Tuesday Morning

Tuesday Afternoon

Wednesday Morning

Wednesday Afternoon

Thursday Morning

Thursday Afternoon

Friday Morning

Friday Afternoon

Saturday Morning

Saturday Afternoon

Volunteer Types

* What language(s) do you speak?

Additional Information

Are you a current University of Miami (UM) student?

Are you a Miller School of Medicine (MSOM) Medical Student?

Are you a current Univeristy of Miami (UM)/Miller School of Medicine (MSOM) Graduate or PhD Student?

Have you ever been a trained or volunteered at UM/MSOM?

If yes, please indicate:

* Start Date

* End Date

* Volunteer Position

* UHealth Department

* Location

* Contact / Supervisor

Name(s) and Department(s) of family members employed at UHealth (if applicable):

* Graduation Year

Citizenship Status:

Do you have an F1 Visa?

References

Please provide a professional or academic reference below. References from friends or family members will not be accepted.

* Name

* Relationship

* Telephone

* E-mail Address

* Name

* Relationship

* Telephone

* E-mail Address

Education, Training, and Interest

* Relevant Education - If student, indicate: Academic Affiliation

* Relevant training, skills, and experience:

* Why do you choose to volunteer at UHealth?

Signature

I certify that all statements in this application are true. I also agree that if I am accepted as a volunteer, I will abide by all regulations of UHealth.

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Applicant's Signature