Dear Prospective Volunteer:

Thank you for your interest in volunteering at Portsmouth Regional Hospital. Volunteers provide service in a variety of areas of the hospital and are an integral part of our community. The information you provide will be stored in confidence. Your completed form will be held securely and confidentially.

Items to consider:

  • Portsmouth Regional Hospital has a policy of conducting background investigations for all volunteer applicants prior to beginning a volunteer experience.
  • Minimum commitment is 3-4 hours per week for 6 months.
  • Minimum age is 14 years old.
  • Before starting service, all applicants will be referred to the Occupational Health Department for medical clearance (flu shot and applicable immunizations).
  • All applicants will be required to attend orientation and training.
  • Please complete all applicable information on the Volunteer Application.
  • Falsification of information on either the Volunteer Application may be grounds for denial of a volunteer placement.
  • Portsmouth Regional Hospital is not obligated to provide a volunteer placement, nor is the applicant obligated to accept a position, if offered.

All fields with an asterisk (*) are required.

Thank You

The form was submitted successfully.

2022-CAP-Portsmouth Regional Hospital-Volunteer Application-PI

Contact Information



When are you available for volunteer service?


College Graduate
Assignment Preference (check all that interest you)
Special Skills or Qualifications

Emergency Contact


Two References (not related to you)

Reference 1 Name
Reference 2 Name

Agreement and Signature

I understand and agree that submitting this application form does not automatically register me as a Portsmouth Regional Hospital volunteer, and that placement as a volunteer is based on current needs matching my skills. I also understand that there are certain additional qualifications I must meet, including a background check, hospital orientation, health clearance (flu shot, immunizations) and the acceptance of established volunteer policies and procedures before I may begin volunteering.

Please check after reading each statement and then sign and date: