1233 North 30th Street, Billings, MT 59101      406-237-7000
St. Vincent Healthcare
 
 
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Student Volunteer Application & Photo Consent 2014

For new and returning volunteers. Deadline-April 24, 2014

Reminder: Complete the minimum 300 word essay at the end of the application.




* Indicates required information
Personal Data 
First Name * 
Last Name * 
Name You Go By * 
Gender * 
Age Today * 
Date of Birth * 
Address * 
City * 
State * 
Zip * 
Home Phone * 
Mother's Work Phone 
Father's Work Phone 
Email 
Parent / Guardians * 
Name of School Next Year * 
Grade Next Year 
What Year Will You Graduate 
Character References (Not Relatives) 
Reference #1 
Name * 
Relationship * 
Home Phone * 
Work Phone 
Reference #2 
Name * 
Relationship * 
Home Phone * 
Work Phone 
More About You 
Volunteer Experience 
Activities (school, church, etc.) 
What motivated you to become a Student Volunteer? 
What careers are you interested in? 
Summer 2014 Volunteer Opportunities 
Please Check One * 

First Choice * 
Second Choice 
Mandatory Orientation Dates - Select one date that you will be able to attend * 

Volunteer days of the week - Select days you will be able to volunteer (only one day will be assigned) 




Volunteer Shift Preferred * 

Would you like to earn extra credit hours by helping with special events throughout the Summer? * 

IMPORTANT - PLEASE READ AND SIGN 
Acceptance of Terms 
Re-Type Name as Signature * 
Photo Consent 
First Name 
Last Name 
Date * 
Parent / Guardian Signature * 
Health Report 
First Name 
Last Name 
Home Phone 
Address 
City 
State 
Zip 
Age Today 
Date of Birth 
Personal Physician 
Physician Phone 
Are you presently under a physicians care? * 

If Yes, why? 
Have you been on any medications for an extended length of time? * 

If Yes, what medications? 
Date of MMR or Rubella Vacination 
Have you had any of the following? 
 
Please explain 
 

Please explain 
 
Please explain 
In Case of Emergency Notify: 
Name * 
Relationship * 
Home Phone * 
Work Phone 
Company Name 
ESSAY * 
IMPORTANT - applications without parental signatures will not be processed