Volunteer at Kaiser Santa Rosa

Please Select: *

Adult

Junior (age 15-18 years)

* denotes a required field

Name: *

Last, First, Middle

Date of Birth: *

Day/Month

How Did You Learn About the Kaiser Permanente Volunteer Program: *

Have You Ever Volunteered at any Kaiser Permanente Facility: *

Yes

Why Are You Seeking to Volunteer: *

Personal Commitment

School Program

Emergency Contact Name: *

Emergency Contact Phone Number: *

Date of Birth For Junior Volunteers (15-18 Years):

School Attending (Junior Volunteers Only):

I certify that all answers in this Volunteer application are true and correct, and have been given voluntarily: *

Yes

I understand that volunteering requires a minimum of four (4) hours per week for adults and two (2) for juniors for a minimum of one year: *

Yes

I understand 18 years of age and above will be required to have a background check: *

Yes

Digital Signature: *

By typing my name in this box, I digitally sign this Volunteer application and verify that I am who I say I am.

Parent/Guardian Signature For Junior Volunteers:

By typing my name in this box, I digitally sign this Volunteer application and verify that I am the parent/guardian of the junior applicant and I give permission for the junior applicant to apply as a Volunteer for Kaiser Permanente.

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Volunteer at Kaiser Santa Rosa