Required fields are marked with an asterisk *. Note: For security purposes this form will expire after 30 minutes and it will not submit.First Name *Last Name *Middle InitialStreet Address *City *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Phone Number *Date of Birth *Email *Parent/Guardian Name *Parent/Guardian Phone Number *Emergency Contact Name *Emergency Contact's Relationship To You *Emergency Contact's Phone Number *Name of Your SchoolGradeList school clubs and organizations you're a member of:If interested in a health career, which field?List previous volunteer experience:List dates of vacations, summer camp, and other dates not available:Reasons for wanting to become a Junior Volunteer: *You will be allowed to volunteer three days each week. Please check preferred days: Monday Tuesday Wednesday Thursday FridayPlease check preferred hours: 8:00 am - 12:00 pm 12:00 noon - 4:00 pm 5:00 pm - 7:00 pmI hereby apply for volunteer service with John Randolph Medical Center. I understand and agree to comply with the requirements and regulations of the Medical Center and to consider all privileged information concerning the hospital, its patients and staff strictly confidential. I will take all criticisms and problems to the Director of Patient Support Services. If it is felt in the best interest of the Medical Center, I can be relieved of all of my volunteer responsibilities.I give permission to John Randolph Medical Center to use my picture or likeness, which may be taken at the hospital, activity or event for use in advertising, promotional materials, website display, posters or publications.Signature (Type your name) *Date * Rate Your Experience Submit SuccessThe form was successfully sent. There was an error with the form submission.