Volunteer Application
Complete the form below to join our volunteer team!

Personal Information
Last Name:
First Name:
Street:
City/State/Zip:
Home Phone:
Cell Phone:
E-Mail:
Date Of Birth (MM/DD/YY):

Employer
Name:
Street:
City/State/Zip:
Phone:

College/University Student
Name Of School:
Campus:

In Case Of Emergency/Illness
Contact:
Relationship:
Cell Phone:
Home Phone:
Business Phone:

Why Are You Interested In Our Volunteer Program?


Please List Any Prior Volunteer Experience:


Education
Last Year Completed:
Degree:

Languages
What Languages Do You Speak?

Volunteer Preferences
Patient Care Services — Yes No
Office Services — Yes No
Other Interests (Please List):


References
Two reference letters are required — one personal, one business, no family members. Please have reference letters sent to:

Denise Whitley
Coordinator of Volunteer Services
7600 River Road
North Bergen, NJ 07047
Fax: (201) 854-5748
E-Mail: [email protected]

Availability
Please note hours available in appropriate spaces.
(Actual commitment time will be determined during interview with the Coordinator of Volunteer Services.)
 Sunday:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:

I agree to abide by the requirements and regulations of Palisades Medical Center and the service to which I am assigned. I will serve a minimum of eighty (80) hours after participating in required training. Letters of recommendation will not be issued prior to completion of 80 hours of volunteer time.

I authorize Palisades Medical Center and the Palisades Medical Center Foundation to use my name and/or photograph in marketing materials to help promote Volunteer Services at Palisades Medical Center.
Please check one — Yes No

Retype Full Name For Signature:
Date:


Thank you for your application. A Palisades Medical Center staff member will contact you as volunteer positions become available.

Note — Completion of this application does not guarantee a volunteer position with the organization.
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HACKENSACK MERIDIAN HEALTH PALISADES MEDICAL CENTER  •  THE HARBORAGE
7600 River Road, North Bergen, New Jersey, 07047  •  (201) 854-5008