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Internal Volunteer Application Form

What's your email address?

Your information


Required fields are marked with an asterisk (*). 12 fields below are a file upload/attachment, the size of all uploaded files must be less than 10MB.
First name *
Last Name *
Cell Phone *

For example, 123-456-7890
SMS/text messaging: By providing your mobile number and checking the box below, Family Health West Foundation will be allowed to send you SMS (text) messages relating to their volunteer activities. To opt-out, reply STOP to any SMS message OR return to this form and uncheck the box.
Street address 1 *
Street address 2
City *
State *
Zip *
Birthdate *

A valid date as MM/DD/YYYY (for example: 11/30/2015)
Shirt Size *
Privacy Notice
The information you submit through this online form is protected using Secure Sockets Layer (SSL) technology. This means that your information is encrypted as it travels between your computer and our volunteer database. This is the same technology used by banks to protect online banking services and online merchants to protect credit card information. Once your data reaches our volunteer database, it is protected by hardware firewalls, secure servers, database encryption, and other security measures.
3 References *
Back Ground Results

The total size of any/all file uploads must be less than 10MB
Drug Screen Results

The total size of any/all file uploads must be less than 10MB
TB Testing

The total size of any/all file uploads must be less than 10MB
Confidentiality Agreement

The total size of any/all file uploads must be less than 10MB
Immunization Records

The total size of any/all file uploads must be less than 10MB
Current Seasonal Flu Shot

The total size of any/all file uploads must be less than 10MB
COVID Vaccine

The total size of any/all file uploads must be less than 10MB
Drivers License or ID

The total size of any/all file uploads must be less than 10MB
Background Check Authorization

The total size of any/all file uploads must be less than 10MB
MCC Request for Testing

The total size of any/all file uploads must be less than 10MB
Compliance Training

The total size of any/all file uploads must be less than 10MB

Terms & Conditions

By Clicking "Submit Application" I hereby authorize Family Health West to contact me and my listed references and use the information entered on this form for the Volunteer Application process and file/information storing.

I understand that a condition of volunteering at Family Health West is a screening test for tuberculosis. Upon completion of the volunteer interview and initial volunteer onboarding process, it is the responsibility of the volunteer or the parent of the volunteen to contact the TB Nurse at 970-858-2190 to schedule their TB test, the follow-up visit, the second TB test and the second follow up visit.
If the results of this test are positive, I understand that a chest x-ray will be done. Family Health West agrees to do the screen and/or x-ray free of charge.

I acknowledge that I will also be required to complete a drug screening prior to volunteer service. Family Health West is determined to eliminate the use of illegal drugs, alcohol, and controlled substances. This program is designed solely for the benefit of volunteers and employees, to provide reasonable safety while on duty, and to protect them and patients/residents from offending individuals. Additionally, this program meets Family Health West's commitment to the community it serves.

All volunteers are required to have a flu shot (October - March) and COVID vaccine per the state guidelines.

Submitting an application will act as my authorization signature or that of a parent or guardian who agrees to the above.

I agree that a facsimile (fax), electronic or photographic copy of this Authorization shall be valid as the original.
I Agree