Detroit Lakes Adult Volunteer Application

Please create your desired User ID and Password above.

(User ID must be a valid email)

For help contact:

Essentia Health-St. Mary's Volunteers Detroit Lakes

Contact:

Cara Frank

Cara.Frank@EssentiaHealth.org

Volunteer Services

1027 Washington Avenue

Detroit Lakes, MN 56501

218-847-0867

Adult Volunteer Application

Volunteer Services Mission Statement

Volunteer Services is dedicated to provide the highest

quality of volunteer support to those we serve within the region

**Please advise us if any accommodation is needed to participate in the application process.**

Personal Information

* Family/last name

* First name

Middle name

* Address

* City

* State

* Zip/postal

* E-mail

* Primary Phone

Secondary Phone

DOB

Gender

Emergency Contact

* Contact name

* Primary Phone

Secondary Phone

* Relationship to Volunteer

Have you ever been employed by Essentia Health?

Dates Employed:

Facility/Department

Your Name at the time

Have you ever been convicted of a criminal offense?

Have you ever been charged with neglect, abuse or assault?

Do you use illegal drugs?

Have you ever been exposed to Tuberculosis (TB) or had a positive skin test to TB?

Placement Information

* How did you hear about volunteering?

* Why do you want to volunteer?

List other volunteer work you have done in the past.

Tell us about any special talents, skills or trainings you think could be applied at Essentia Health.

References - Do Not List Relatives

Reference 1:

Name

Day Time Phone

Complete Address

City

State

Zip/postal

Reference 2:

Name

Day Time Phone

Complete Address

City

State

Zip/postal

___________________________________________________________________________________________________________________

I hereby authorize investigation of all statements contained in this application. I further authorize my reference permission to furnish Essentia Health with facts and opinions as to my job performance, capabilities and desirability as a volunteer. I further release all persons whomsoever from any damage because of furnishing said information.

* The information in this application is accurate and correct to the best of my knowledge.

I agree as a volunteer my time and talents will be given freely without any expectation of monetary reimbursement.

I am participating in a community program, which reimburses me for volunteer service hours.

* My typed name shall have the same force and effect as my written signature.

* Your Signature

* Date

Volunteer opportunities are provided without regard to religion, creed, race, national origin, sexual orientation, age, gender, disability, marital status or status with regard to public assistance. Essentia Health does not imply that you will be assigned a volunteer position and this application should not be construed as a contract or promise of a volunteer position.

Adult Volunteer Form 2020