Adult Volunteer Application

Please fill-up the online form then submit or you may download the Adult Volunteer Application and mail to CCRMC Volunteer Office 2500 Alhambra Avenue, Martinez, CA 94553. See also Doula Volunteers.

Online Adult Volunteer Application Form

First Name:
Middle Initial:
Last Name:
Street Address:
City:
Zip Code:
Home Phone:		Area Code first
Cell Phone:
Business Phone:
Email:
How did you hear about the CCRMC volunteer program?		Current/Former volunteer Former Patient Staff Member CCRMC Website Contra Costa County Volunteer Center Other
Please list any language you speak fluently, besides English:
EMPLOYMENT:
Current Employment Status:		County Employee Full Time Part Time On Call Retired Unemployed
Current Employer: Address:
Previous Employer: Address:

EMERGENCY CONTACT INFORMATION:
Name	Contact Number	Relationship
1.
2.
Do you have a health problem we should be aware of in case of emergency?	Yes No (If yes, please describe - such as history of back trouble, heart, epilepsy, diabetes, fainting, etc.)
Primary Care Physician:
Telephone Number:
Hospital:
Dentist:
Telephone Number:
Address:

REFERENCES: In order to process your application, it is essential that all information requested below is provided. References should not be from relatives. References from current or past supervisors are preferred.
1. Name:
Address:
Telephone Number:
Email:
How do you know this person:
2. Name:
Address:
Telephone Number:
Email:
How do you know this person:
To provide a quality volunteer program at the Contra Costa Regional Medical Center and to insure that we do our best to match the needs of the Hospital and our Volunteers, we ask a certain amount of detailed information regarding your personal and work related experiences. With this information we are better able to offer you an assignment that can be tailored to your needs as well as ours.
EDUCATION:
2-Year College Completed Adult Education	4-Year College Completed Currently Enrolled	Graduate Studies Area of Study:
Please note any ORGANIZATION AFFILIATIONS that you have:
ADDITIONAL INFORMATION:
Are you willing to be called to serve as a volunteer in the event of a County wide emergency such as an Earthquake or Flood:		Yes No
Are you doing volunteer work as an education requirement?		Yes No If yes, how many hours are required?
You are invited to join our auxiliary. Would you be interested?		Yes No
Would you be willing to serve in a capacity that might require patient contact?		Yes No
Would you be willing to push a wheelchair if needed?		Yes No
Have you had any previous experience as a volunteer? If so, with what organizations, and what kind of work did you do?
Why, at this particular time in your life have you chosen to volunteer with us?
What do you hope to gain from being a volunteer?
What life experiences have you had that might be useful to you in volunteering with our hospital?
I understand that I am volunteering my services to Contra Costa Regional Medical Center and/or Health Centers without promise or expectation of compensation or future employment. I further agree to serve as a volunteer for a minimum of 200 hours within the calendar year. (Please check to agree/proceed.)
Disclaimer: Applicants will be required to submit an application, participate in a face-to-face interview, provide references for checking, complete a background check, and attend a training program prior to placement. Applicants who provide false information shall be disqualified for, or terminated from service.
Enter the numbers: