Enrollment - Samaritan Center

Please enroll by completing the following form and then clicking the Submit button. Please remember that you must click the Submit button at the bottom of this page for your enrollment to be processed.

General Information

Name

Cell

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Address

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Preferred First Name

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Preferred Pronouns
Individual Application
Group Application (If you are completing a volunteer application for a group, please enter the group's name below)
Name of Group or Organization

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Emergency Contact Name

0 / 100
Emergency Contact Phone Number

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Current Status - May Choose Multiple

Select one or more...

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Place of employment

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Are you a student in need of service hours?
If so, where do you attend school?

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Please list any limitations that will impact your ability to volunteer

0 / 100
I acknowledge that Samaritan Center DOES NOT provide documentation for court mandated or other legal related volunteer hours.
In consideration of being allowed to volunteer my services at the Samaritan Center I hereby acknowledge that there are certain risks of injury involved and I knowingly and freely assume all such risks and assume full responsibility for my participation - To the extent allowed by law I agree to indemnify and hold harmless the Samaritan Center its officers employees agents representatives and volunteers of all liabilities and all loss or damage to person or property which may occur or be incident to my involvement or participation - By submitting this form I am agreeing on behalf of myself . By electronically signing this form you are agreeing to the conditions as outlined as a potential volunteer PLEASE ENTER TODAY'S DATE BELOW

Please make sure to click the "Submit" button at the bottom of this page when finished.

Additional notes or comments

Please make sure to click the "Submit" button at the bottom of this page when finished.

Your enrollment form has been submitted.

You will be notified by email when your enrollment form is processed. If another person would like to enroll from this computer you can start over with a new form.