MyMichigan Health General Teen

*This application is for students who are over the age of 14 and a current high school student

Thank you for your interest in volunteering at MyMichigan Health! Please allow yourself approximately 10 minutes to accurately and thoroughly complete this volunteer application. If you have trouble completing this application, please contact the Volunteer Services Department.

**Volunteer Services is not able to offer hours towards clinical experience, job shadowing, internship or court-appointed community service. Please reach out to the Workforce Development office at 989-839- 1307 if you are looking for hours for one of these purposes.**

New User Details

User ID

User ID (verify)

Password

Password (verify)

Location you are interested in Volunteering:

Personal Information

* Given/First name

Middle Initial

* Family/Last Name

Please list any other last names used (maiden, alias, etc.):

* DOB (MM/DD/YYYY)

Gender

* Street Address

Apartment/Suite No. or P.O. Box

* City

State (as combo)

* Zip/postal

* Preferred Phone Number

Phone (Mobile)

Phone (Work)

E-mail (if you do not have an email address, please leave this field blank)

Background Information

Have you ever been a volunteer for MyMichigan Health?

Have you ever been employed by MyMichigan Health?

If Yes, please list dates of service:

Have you ever been convicted of a crime other than a traffic offense?

If yes, please explain:

Volunteer Information

Please select all that apply:

If your current status is College Student and your volunteer hours are required for a course or program, please list the following: College Name College Course or Program Professor or Advisor Name Hours required to complete

What area of volunteer service are you most interested in doing? (Check all that apply)

* Date available to begin:

How frequently would you like to volunteer and do you have preferred days of the week?

Emergency Contact Information

* Name of Person to Notify (First & Last Name):

* Relationship (spouse, parent, friend, etc.):

* Phone (Home)

Phone (Mobile)

Phone (Business)

Applicant Statement

I acknowledge that the information I have supplied is correct to the best of my knowledge and understand that any deliberate falsifications, misrepresentations or omissions of fact may be grounds for rejection of my application or dismissal from the volunteer program. I understand that consideration for volunteer placement is contingent upon the results of reference, screening for TB and background checks including a criminal check. I therefore authorize MYMichigan Health to invesitgate all statements made on my application and to discuss the results of the investigation with those responsible for volunteer selection and placement. If accepted for volunteer placement, I will comply with the values, policies and procedures of MyMichigan Health in effect or revisions which may be issued in the future. Misrepresentation of facts constitutes cause for separation from volunteer placement. I understand that the position that I am applying for is an unpaid volunteer position.

* Please type your name to agree to the application statement: