Volunteer Interest Form

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Primary Phone:*

Secondary Phone:

Email:*

The best way to reach me:*

Phone Contact
Email
No Preference

Best time(s):*

How / where I’d like to volunteer:*

Kline Galland Home
The Mary Schwartz Summit (formerly The Summit at First Hill)
Kline Galland Hospice
Polack Adult Day Center
I’m not sure

(Check all that apply)

Special Interests:

I understand and agree that submitting this form: 1) does not automatically qualify or register me as a Kline Galland Volunteer, 2) there will be specific background checks I must clear, and 3) there may be other qualifications I must meet, (including the acceptance of established volunteer policies and procedures) before I may begin volunteering. I attest that the information I have provided on this form is true and accurate.*

I Agree

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Name

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