Midstate Adult application

VOLUNTEER APPLICATION
Qualified volunteer applicants are considered without regard to race, color, religion, sex, national origin, age,marital status, or the presence of non-job related medical condition or disability.
Name prefix
First name
Middle Initial
Family/last name
Street
Apt/Suite
City
State
Zip/postal
Phone (Home)
E-mail
Phone (Cell)
In case of emergency, notify:
Phone
Relationship
________________________________________________________________________________________________________________________________________________________________________________________
Experience
Education:
Name of school
Did you graduate?
Field of study
Name of school
Did you graduate?
Field of study
Work Experience:
Employer
Position
When?
Employer
Position
When?
Previous Volunteer Experience:
Agency name
City/State
Type of service
When?
Agency name
City/State
Type of service
When?
_______________________________________________________________________________________________________________________________________________________________________________________
References
Please provide two academic, professional, or volunteer references who are not related to you:
1:
Name
Street
City
State
Zip/postal
Relationship
Phone
E-mail
2:
Name
Street
City
State
Zip/postal
Relationship
Phone
E-mail
_____________________________________________________________________________________________________________________________________________________________________________________
Have you ever been convicted of or had a finding rendered by a court concerning a crime?
If yes, please specify: (Note: Conviction of a crime is not necessarily grounds for disqualification)
How did you learn about the volunteer opportunities at MidState Medical Center?
List special skills or interests as they apply to the volunteer position, including other languages spoken:
Do you currently hold any certification or licensure? If so, please list:
______________________________________________________________________________________________________________________________________________________________________________________________
Availability and Assignment Request
Please list times you are available to volunteer:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Times Available
Schedule Preference (include day of week and time period):
First Choice:
From:
To:
Second Choice:
From:
To:
Assignment Request:
__________________________________________________________________________________________________________________________________________________________________________________________
Applicant's Statement
I authorize the Volunteer Office to contact the references provided by me to obtain the information pertinent to myresponsibilities as a volunteer at MIDSTATE Medical Center.

I agree to abide by the policies and regulations of MidState Medical Center and the Volunteer Services Department andto participate in orientation and training required by the Medical Center.

I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients orpersonnel and not seek to obtain confidential information from a patient.

I understand that I may be dismissed from my duties if I fail to comply with hospital policies and procedures, willfulwrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or anyother circumstances deemed contrary by the Manager of Volunteer Services to the best interests of the hospital.

I certify that the facts set forth in this application are true and complete to the best of my knowledge.I understand that if I am accepted into the Volunteer Services program, false statements may result in my dismissal.

I understand that I am expected to inform the Department of Volunteer Services of any significant change inmy health status that would negatively impact on my ability to perform the tasks to which I am assigned.

Signature
Date