Volunteer - Senior Dental Center

Volunteer Role

What volunteer position are you interested in?*

Personal Information

Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Birthdate

Preferred Phone

Email*

Emergency Contact Information

Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone

Alternate Phone

Relationship

Education Information

Name of School

Licenses

Year Graduated

Certificates

Name of School

Credentials

Year Graduated

Other

Languages

Speak

Read

Write

Volunteer Time Commitment

How long do you plan to volunteer?

From

To

How many hours/days per month:

What days can you volunteer:*

What times can you volunteer?*

7:30am - 12:00pm (mornings)
12:30pm - 4:30pm (afternoons)
7:30am - 4:30pm (all day)

(We request that all volunteer shifts are a minimum of 4 hours).

Volunteer Experience

Briefly describe your previous work/volunteer experience and how it aligns with the Senior Dental Center opportunity you are applying for.

Volunteer Expectations

As a volunteer of the Gary and Mary West Senior Dental Center, you understand and agree to:

Adhere to all applicable company policies and procedures

Adhere to all company confidentiality and HIPAA policies

You can download the Volunteer Handbook here

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Phone

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