Extended Care Center    Behavioral Medicine Center    Medical Rehabilitation Center



 

VOLUNTEER SERVICES DEPARTMENT
HealthSource Saginaw, Inc.
3340 Hospital Road -- P.O. Box 6280
Saginaw, MI  48608-6280

VOLUNTEER REGISTRATION FORM

THE INFORMATION ON THIS FORM WILL HELP US TO FIND THE MOST SATISFYING AND APPROPRIATE VOLUNTEER SERVICE FOR YOU.  YOUR COOPERATION IN COMPLETING THIS FORM IS MOST APPRECIATED. 

Name:
Home Address:
City:
State:
Zip:
Home Telephone:
  Date of Birth:
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Education:
Emergency Contact Name/Relationship:   Phone:
Previous Work Experience:
Are you presently employed?     If Yes, hours per week:
Your current duties are: 
Employer's name and address: 
Special skills, interests, training or hobbies: 
Time you have available for volunteer work: 
Required hours:    Deadline Date:
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Hours per week:    Regularly each week:
Almost any time:    
REFERENCES: (Excluding family/friends)
 1) Name:   Phone:
 2) Name:   Phone:
CONFIDENTIALITY STATEMENT
I UNDERSTAND AND AGREE THAT IN THE PERFORMANCE OF MY DUTIES AS AN AUXILIAN AND/OR VOLUNTEER OF HEALTHSOURCE SAGINAW, INC., I MUST HOLD PATIENT/RESIDENT/CLIENT INFORMATION IN CONFIDENCE. I UNDERSTAND THAT INTENTIONAL OR VOLUNTARY VIOLATION OF PATIENT/RESIDENT/CLIENT CONFIDENTIALITY MAY BE CAUSE FOR IMMEDIATE TERMINATION OF MY SERVICES TO HEALTHSOURCE SAGINAW, INC. AND COULD RESULT IN POSSIBLE FINES AND/OR IMPRISONMENT.

 
 
Phone: 989/790.7700     Toll Free: 800/662.6848     3340 Hospital Rd., Saginaw, MI 48603