Volunteer Application Form

Date:
Name:
Street Address:
City, State, ZIP:
Phone Number:
Alternate Phone:
Email 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  
Tuesday  
Wednesday  
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.