Volunteer Application For McLaren Flint

McLaren Flint Auxiliary Membership Application

Please note: After your application and background check have been processed, you will be contacted for your personal interview with the Director of Volunteers.

Note: Fields marked with an * indicates required field

Date: *

Name (Last, First, Middle Initial): *

Address: *

City-State: *

Zip Code: *

Home or Cell Phone: *

In case of emergency, contact (include name, phone and relationship): *

Email Addresss: *

Gender: *

male

female

Birthday (Month - Day - Year): *

EDUCATIONAL BACKGROUND

Name of High School:

Graduated?

Yes

Graduation Year:

Name of College:

Degree:

Graduation Year:

Name of Post Graduate School

Post Degree

Graduation Year:

Are you a current college student?

Yes

PERSONAL INTERESTS/HOBBIES

Please list interests and hobbies:

I am interested in becoming a volunteer because:

Who has prompted you to apply for membership in McLaren Auxiliary?

PRIOR WORK HISTORY

Employer and Position:

Telephone Number:

Date of Employment:

Employer and Position:

Telephone Number:

Date of Employment:

REFERENCES (Other Than Relatives)

Personal Reference (and relationship): *

Phone Number: *

Personal Reference (and relationship) : *

Phone Number: *

Personal Reference (and relationship) : *

Phone Number: *

Have you ever been convicted of a felony, or have any pending?

Yes

If yes, state charge, date, disposition:

I authorize McLaren Health Care and its affiliates or its designated agents to make whatever inquiries it may deem necessary in connection with my application for volunteer service. As part of such inquiries, McLaren has my permission to contact persons who may have information relating to my suitability to perform volunteer duties. *

Permission to perform a background check (yes)

Signature: (Typing your name here indicates that all of the above information is accurate and acts as your electronic signature.)*

If you would like a printed copy of this completed form, please do a file/print before clicking submit.

Captcha*