541-771-1765
www.smilecentraloregon.com
VOLUNTEER VOUCHER
Patient Name
*
First Name
Last Name
Who volunteered?
*
I did (the patient)
Someone else
I am the patient's
PARENT
SIBLING
OTHER
Volunteer Name
First Name
Last Name
Volunteer Hours Start Date
*
-
Year
-
Month
Day
Date
Volunteer Hours End Date
*
-
Year
-
Month
Day
Date
FILL IN THE TOTAL HOURS YOU WORKED EACH DAY
Total Hours (# Only)
Monday (Start of Week)
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday (End of the Week)
Total Hours
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Volunteer Coordinator Name
*
First Name
Last Name
Volunteer Coordinator Email
*
Phone Number*
*
-
Area Code
Phone Number
*The volunteer coordinator may be contacted to confirm hours.
Volunteer Coordinator Signature
*
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