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Volunteer Application Form

Date:
Name:
Mailing Address:
Please indicate the type of volunteer work in which you are trained or have experience:
MD/DO   DDS   Dental Assistant   Dental Hygienist   Nurse Practitioner   Physicians Assistant   RN   LPN   Physical Therapist   Medical Assistant   Social Worker   Lab Tech   Nutritionist   Dietician   Counselor   Secretary   Medical Records Librarian   Pharmacist   Pharmacy Tech   Health Educator   Other  

If you are trained in a specialty of one of the above, please tell us what that specialty is (e.g. endodontist, Family Nurse Practitioner, etc.)
Please indicate the area or position in which you are interested:
The profession I indicated above   Cleaning Crew   Materials Management   Building Maintenance   Greeter/Escort   Registering Patients/Appointments   Publicity/Newsletter   Dental Clinic Aide   Spanish Interpreter   Answering/Making Telephone Calls   Gofer (I'll Do Anything)   Computer Specialist   Child Care (in Good Samaritan Building)  
Other skills, experience and/or information that would be helpful to us:
We're not asking for a commitment at this time, but the following information will be helpful as we plan:
I estimate that I will be able to volunteer hours a week or hours a month.

What day(s) of the week are you most likely to be available to volunteer at Good Samaritan?
Monday  TuesdayWednesday  Thursday  Friday  
Are you interested in contributing financially to Good Samaritan? Thank you for your generosity - it will make a difference!

Once your donation is received, a letter acknowledging your gift will be sent to you. All donations are tax deductible.

For questions regarding a donation to the Good Samaritan Health and Wellness Center,
please call (706) 253-4673.