Belton Regional Medical Center

Volunteer Application

17065 S. 71 Highway
Belton, Missouri 64012
Volunteer Services (816) 348-1201

Required fields are marked with an asterisk *.

Contact Information

Emergency Contact

Education and Experience


(IMPORTANT: List at least 3 references from a business, school, clergy or other volunteer experience. Do not use physicians or relatives.)




Availability and Confirmation

Day(s) Available *
Would you be interested in other volunteer service at the hospital?
Have you ever been convicted of a crime other than a parking ticket? *

Conviction will not necessarily disqualify individuals from volunteer services

I affirm that the information provided on this application is true and complete. I understand that before I begin my volunteer service, I will be interviewed, consent to a reference check (Background History Record Information), attend orientation, and provide proof of TB skin testing or I will receive necessary required testing prior to beginning my volunteer service. I understand that this application does not guarantee a volunteer placement at Belton Regional Medical Center and that if accepted, I will not receive payment for my service.


The form was successfully sent.

There was an error with the form submission.