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Check the Location of Your Choice	Community General Campus Polyclinic Campus Harrisburg Campus Fredricksen Outpatient Center
Date:
First Name:
Last Name:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Have you lived in the state of Pennsylvania consecutively for the last 2 years?	yes no
Telephone:	() -Second partThird part
Date of Birth:
E-mail:
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Previous Volunteer Experience:
Training, Skills or Interests:
Hobbies or Languages Spoken:
Organizations or Affiliations:
Are you needing to volunteer for court ordered community service?(*Please note: PinnacleHealth does not accept court ordered community service volunteers. We recommend checking with local food banks or libraries nearest you for these opportunities)	YesNo
Have you ever pleaded guilty or been convicted of a felony or misdemeanor, civilian or military? Do not list minor traffic violations.	YesNo
Time Availability:
Hours Availability (*PinnacleHealth requests volunteers commit to a minimum of 50 volunteer hours within a 1 year period.)
Area(s) of Preference:
Emergency Contact Name:
Emergency Contact Number:	() -Second partThird part
Emergency Contact Relationship:
May we call you for last minute substitute work?	YesNo
Reference 1 Name:
Reference 1 Address:
Reference 1 Phone #:	() -Second partThird part
Reference 2 Name:
Reference 2 Address:
Reference 2 Phone #:	() -Second partThird part

Online Volunteer Application