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Volunteer Application

Olympia Medical Center
5900 W. Olympic Blvd.
Los Angeles, CA 90036


Fax: 323-932-5160

First Name:*
Middle Name:
Last Name:*
Home Address:*
City:*  State:*   ZIP:*
Home Phone:*
Cell Phone:
Date of Birth:*
Social Security Number:*
E-mail Address:


Emergency Contact:*
Emergency Contact's Home Phone:*
Emergency Contact's Cell Phone:
Emergency Contact's Work Phone:
Your Doctor's Name:*
Doctor's Phone:*
Do you have any physical limitation or mental disorder that would impair your ability to perform as a volunteer in the Medical Center without any supplemental assistance?*

If yes, explain:
Have you ever been arrested or convicted of a crime? (An affirmative response will not automatically disqualify you from being considered.):*

If yes, explain:

Name of friends and/or relatives employed or volunteering at Olympia Medical Center

*Note: It is against hospital policy for family members to work in the same department.

Volunteer Experience

Activity 1:
Activity 1: Type of Duties Performed:
Activity 1: Date(s):
Activity 2:
Activity 2: Type of Duties Performed:
Activity 2: Date(s):
Activity 3:
Activity 3: Type of Duties Performed:
Activity 3: Date(s):
Why would you like to volunteer at Olympia Medical Center?*

Volunteer Shifts

We ask you to commit to a 4 hour shift twice a week. To help us schedule you, please select 2 shifts that would work with your schedule. Please indicate the day and shift.

Note: we'll only schedule you for 2 shifts. Also, please indicate which type of volunteer assignment you would prefer: Clerical or Clinical.

Assignments are done on a first-come, first-serve basis.
Shift 1 Option - Time:*

Shift 1 Option - Day:*
Shift 2 Option - Time:*

Shift 2 Option - Day:*
Please select the type of assignment you would prefer.*

Applicant's Statement

I hereby affirm that the information provided on this application is true and complete to the best of my knowledge, and agree to have any of the statements checked by the organizing or its representatives. I understand that providing any false or misleading information or any omissions may disqualify me from further consideration as a volunteer and may result in my immediate termination even if discovered at a later date.

I authorize representatives of Olympia Medical Center to conduct a thorough investigation of my activities and authorize all references provided in this application, as well as other individuals, whom the Organization or it representative may contact, to provide all information they have about me. Further I agree to cooperate in such investigation, and release from all liability or responsibility of the Organization, all persons and entities acting on its behalf, and all persons and entities requesting or supplying such information.
Volunteer Name:*