McLaren Flint Auxiliary Membership Application

*Indicates required information. If incomplete, will not send.

Date *

Name (Last, First, Middle Initial) *

Address *

City/State *

Zip *

Home or Cell Phone *

In case of emergency, contact (include name, phone & relationship) *

E-mail Address *

Gender *

Birthday: Month - Day - Year *

EDUCATIONAL BACKGROUND

Name of High School.
Graduated?
Graduation Year:
Name of College:
Degree:
Graduation Year:
Name of Post Graduate School:
Degree:
Graduation Year:
Are you a current college student?

PERSONAL INTERESTS/HOBBIES

Please list interests/hobbies.
I am interested in becoming a volunteer because?
Who has prompted you to apply for membership in McLaren Auxiliary?
I'm interested in (Check all that interest you) *














PRIOR WORK HISTORY

Employer and Position
Telephone Number
Date of Employment
Employer and Position
Telephone Number
Date of Employment

REFERENCES (Other Than Relatives)

Personal Reference (and relationship) *

Phone Number *

Personal Reference (and relationship) *

Phone Number *

Personal Reference (and relationship) *

Phone Number *

Have you ever been convicted of a felony, or have any pending?
If yes, state charge, date, disposition:

I authorize McLaren Health Care and its affiliates or its designated agents to make whatever inquiries it may deem necessary in connection with my application for volunteer service. As part of such inquiries, McLaren has my permission to contact persons who may have information relating to my suitability to perform volunteer duties. *

Signature (Typing your name here indicates that all of the above information is accurate and acts as your electronic signature.) *

If you would like a printed copy of this completed form, please do a file/print before clicking submit.