Volunteer Application – Little Medical School

Contact Information

Name*

First Last

Mobile Phone*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Education

Highest Level of Education*

School Name*

Enter the name of School attending

Current Major*

Which school did you graduate from?*

Degree obtained

Are you CPR Certified?*

Yes
No

Reason for Volunteering*

Select the best choice as it pertains to you

Please Explain why you are applying as a Volunteer*

What School are you currently attending?*

What is the name of the course you are trying to obtain credit for?

Course Director*

Name	Phone	Email	Title

Fill out the information for the person in charge of your course.

Additional information

Why would you make a great Instructor/Junior Instructor?*

Briefly describe any previous volunteer work performed.*

Write None if no previous volunteer experience

What is your experience working with children?*

What is your experience with health sciences?*

Employment History

Do you have previous work experience?*

Yes
No

Previous Work Experience*

Company	Job Title	Dates worked	Supervisor	Phone number

Require accurate information. You are giving us permission to contact previous employers for reference.

Availability

Do you have your own reliable transportation?*

Yes
No

Please explain how you intend to travel to the schools

Available Days to Volunteer*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

You are not committing to a schedule at this time

General Available Times to Volunteer*

During school hours (9a-3p)
After school (3p-5p)
Evenings (5p-8p)
Weekends

You are not committing to a schedule at this time.

Child Safety

Will you be able to pass a thorough background check?*

Yes
No
Not sure

Please explain*

References

Provide at least 2 non-family member references*

Name	Email Address	Phone number	Relationship

How did you hear about this opportunity?*

If you were referred by someone, please list them here.

Resume/CV (optional)

Max. file size: 5 MB.

Background Check Form*

Max. file size: 5 MB.

The background check form may be downloaded here. Please complete and sign this form before uploading.

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