Central Maine Medical Center
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300 Main Street, Lewiston, ME 04240 | 207-795-0111

Online Volunteer Application

Date:

Name:

Address:

(Street, City, State, Zip)

Email Address:

Telephone Number:

Education (last year school completed):

Memberships, clubs & organiziations:

Do you have any hobbies or special interests? If so, please elaborate

Please give a brief description of the types of jobs you have held in the past.

Health, do you have any handicaps or health condition which should be taken into consideration while determining a volunteer assignment?
YES NO
If yes, please explain:

Birthday (month and day only):

Please explain your interest in volunteering at CMMC:

Have you ever been convicted in a court of law? If yes, please explain

Do you have any previous volunteer experience? If yes, please explain

What day(s) and hours are most convenient for you?

Do you have a preference for any specific department in the hospital to perform your volunteer duties?

Please list two (non relative) references; include name and phone number for each. Also, please indicate if you have a family member who works at CMMC.

CMMC-CMHC has my permission to use my picture photographed during my volunteer services for public relations purposes.
Yes No

ATTENTION JOB SHADOWERS, STUDENTS OR ANY APPLICANT BORN AFTER JANUARY 1, 1957:

If you were born after 1957, you will need to provide the Volunteer Services Department with a current copy of your immunization record. To be up-to-date you should have had 2 MMR=s (measles, mumps, rubella) and a tetanus vaccine within the last 10 years. You must provide the Volunteer Department with your record before you begin shadowing or volunteering.
**Also, if you are a job shadower or intern, please dress appropriately - clean clothing (no open toe shoes or blue jeans) and hygiene.

Thank you.