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Home
Services
Behavioral Health Services
Primary Care Services
Student Services
Info
Community Partners & Affiliates
Events
Rates & Insurances
Forms
Volunteer
Donate
Contact
Patient Portal
Donate
Home
Services
Behavioral Health Services
Primary Care Services
Student Services
Info
Community Partners & Affiliates
Events
Rates & Insurances
Forms
Volunteer
Donate
Contact
Menu
Home
Services
Behavioral Health Services
Primary Care Services
Student Services
Info
Community Partners & Affiliates
Events
Rates & Insurances
Forms
Volunteer
Donate
Contact
Patient Portal
SSH-CCBHC VOLUNTEER APPLICATION
Silver State Health VOLUNTEER APPLICATION
Step 1
Step 2
Step 3
Step 4
References
Name
Address
City
State
Zip
Home Phone
Work Phone
Your Email
Previous Volunteer Experience
Occupation (Past occupation if retired)
Other information that will help us make a good match (such as education, general interests/hobbies)
Languages Spoken:
Availability and Volunteer Assignment Preferences
Please Check All That Are Applicable:
I Am Available
Mornings (Mon-Fri)
Afternoons (Mon-Fri)
Evenings (Mon-Fri)
Weekends
Once A Week
More Than Once A Week
One Time Only
As Needed
OTHER
I Could Serve More Than One Person:
Yes
No
Do You Have A Valid (State) Driver’s License?
Yes
No
License Number:
Vehicle License Plate Number
Insurance Company:
Policy #:
Have You Ever Been Convicted For Violation Of Any Laws, Traffic Or Otherwise?
Yes
No
If Yes, Please Explain:
Do You Have Any Physical Condition that May Limit Your Activities?
Yes
No
If Yes, Describe
Who To Notify In Case Of An Emergency?
Telephone Number:
Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.
Name
Phone
Address
Relationship
Name
Phone
Address
Relationship
Name
Phone
Address
Relationship
Comments:
I hereby give my consent to contact my references; to contact my employers, past and present; and to conduct a background check.
Signature Of Applicant
Date