Ambassador Services Online Application

Please use the form below to become a volunteer or complete an internship with Mosaic Life Care.

Full Name (First, Middle, Last):

Street Address:



Zip Code:

Primary Phone:

Secondary Phone (optional):

Date of Birth (MM/DD/YYYY):

Social Security #: (required for background check)



Previous Volunteer Experience:

Occupation (student if a student or past occupation if retired):

Present Employer: (If student list school/major and projected graduation date)

Information that will help us with your volunteer placement (such as education, general interests or hobbies)

Special Skills:

Days available (check all that apply):

AM or PM:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Primary Phone:

Emergency Contact Secondary Phone:

How did you become interested in volunteering at Mosaic Life Care?

Please include two references with email addresses and phone numbers
Reference 1 Name:

Reference 1 Email Address:

Reference 1 Phone:

Reference 2 Name:

Reference 2 Email Address:

Reference 2 Phone:

Please answer the questions below:
Why are you interested in volunteering at Mosaic Life Care?

Describe any volunteer work or experience you think might be helpful to you in this position:

How do you feel customer service should apply to a hospital setting?

If you could create the perfect volunteer job for yourself, what would you be doing?

Have you ever been convicted or a crime other than minor traffic violations in the past five years?

I understand that upon my successful completion of the volunteer placement processes I will become a volunteer. I acknowledge that I will not be compensated for my services and I will not be required to work.

By submitting this form you consent to a criminal background check.