Volunteer/Student Application

Volunteer/Student Application

First Name*

Last Name*

Are you applying as a volunteer, intern, or practicum student?*

Select or enter value

How did you hear about our program?*

If known, which StarCare program?

Select or enter value

If known, which StarCare Supervisor?

Email Address*

Phone Number*

Phone

Local Address*

Permanent Address (if different from local address)

Emergency Contact Information

Name*

Phone Number*

Relation*

Students Only

Which school do you attend?

Which degree/program do you need hours?

What license is your supervisor required to have?*

Requested Start Date

Approximate End Date

Hours Needed

VOLUNTEER CONFIDENTIALITY AGREEMENT

I affirm that the information that I have provided is true and correct to the best of my knowledge. I agree to conform to the StarCare Specialty Health System rules and regulations. I also agree to respect the confidential nature of consumer/patient/participant information as well as information obtained as a result of personal contact. I understand that criminal history, and registry checks will be conducted before my volunteer placement begins. I further agree to inform the Center if I am named in complaints or indictments or convicted of these offenses.

Typed Digital Signature*

Date*

Send me a copy of my responses

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