Skagit Regional Health Volunteer Application

Volunteer Application

Skagit Regional Health
Please Note:

We have stopped active recruitment for the Family Birth Center “Cuddlers”. We have created a waiting list for the position and will reach out to applicants, via email, as needs require. You may continue to submit an application to be added to the waiting list.

Applications for other volunteer positions, like the information desk and gift shop, will be processed as normal.

If applying for both, please complete two seperate applications.
Are you at least 16 years of age?

YesNo
Thank you for your interest in volunteering. However, the minimum age for volunteering is 16. Please consider applying again in the future.
Are you a current employee of Skagit Regional Health?

YesNo
Thank you for your interest.

In almost all cases, current paid employees may not also volunteer in an un-paid capacity. (While we will take a look at each request on a case by case basis, the general rule is that employees may not on an un-paid basis do the same type of work for which they are employed. Other restrictions may also apply.) This is in compliance with the FLSA and our policy "Employee Requests to Volunteer at SRH Facility".
Desired Volunteer Location

Skagit Valley HospitalCascade Valley HospitalOther. Please Specify...
Contact Information
Name

First NameLast Name
Nickname
Last Four SSN
Primary Phone
Alternate Phone
Email
You will receive a confirmation via email once we have received your application.
Street Address
City
State
Zip

Emergency Contact

Who should we call in case of emergency?
Name
Relationship
Emergency Contact Primary Phone
Emergency Contact Alternate Phone
Doctor's Name
Doctor's Phone

Education, Experience and Background

Education

	School Name	Dates Attended	Years Completed	Degree
College
College
High School

Current Employment/Volunteer/School Obligations

	School/Organization/Employer	Position	End Date
Work
School
Other

Work & Volunteer Experience

	Company/Organization	City, State	Dates From-To	Position
Work
Work
Volunteer
Volunteer

Special Skills and Training

Use Web Browser/EmailUse MS OFFICE (Word/Excel)Administrative/Clerical SkillsBilingualOther. Please Specify...
Is there anything else you'd like us to know?

Please provide us with information for at least 2 references. We will email a simple reference form for them to complete on-line. References may be professional or personal.

	Name	Email Address
Reference #1
Reference #2
Reference #3

Please provide us with information for at least 2 references. We will email a simple reference form for them to complete on-line. References may be professional or personal.
Reference #1

First NameLast Name
Email
example@example.com
Reference #2

First NameLast Name
Email
example@example.com
Reference #3

First NameLast Name
Email
example@example.com
OPTIONAL: You may upload additional information (Cover Letter, Resume, Certifications, Licensure, etc.) here.

Cancelof

Volunteer Agreement

My services are donated to the hospital without contemplation of compensation/remuneration, benefits, or future employment from Skagit Regional Health, and given with humanitarian reasons.

I understand that I must provide proof of flu vaccination during declared periods of flu activity. Flu vaccination must occur a minimum of 2 weeks prior to volunteering. If I decline, I may be required to mask while on duty or take other appropriate protective measures.

I understand that volunteers are asked to complete a minimum of 100 hours before requesting recommendations or receiving credit for hours volunteered. As the number of positions is limited, prospective volunteers should apply at least a year in advance of any school deadlines that may be applicable. High school students seeking course or club credit should apply and begin volunteering before their senior year.

I understand that it is the policy of Skagit Regional Health ("SRH") to respect the right of confidentiality for all of our patients and employees and to insist that all volunteers with access to patient confidential information and Protected Health Information at SRH strictly maintain the confidentiality and integrity of this information. "Confidential Information" includes all facts relating to the patient's medical care (past, present or future), including oral information, written information, and any computerized records or data. "Confidential Information" also includes patient financial information, employee records (medical or otherwise) and any other information of a private or sensitive nature at SRH, including financial and operating information of SRH. I agree to strictly adhere to this confidentiality statement.

I hereby certify that there are no willful misrepresentations or falsifications of any of the statements or answers to questions on this application.
Applicant's Signature

Clear
Print Name
Date

MonthDayYear
Date
Parental Consent (Teens 16 through 17)

Your signature indicates your approval for your child's participation in the volunteer program at Skagit Regional Health. You also acknowledge that Skagit Regional health is not liable for any accidents or injury incurred by the student while engaged in the voluntary service.

I hereby grant permission for my child (named below) to be given a flu vaccination and to be screened for the presence of Tuberculosis ("TB") by means of a skin test (referred to as a Mantoux test I understand that if my child has never been tested for TB in the past, a second test will need to be administered within one month of the first test. If the test should produce a positive result I give my permission for a chest x-ray (at no charge) and understand that follow up will be required by the child's physician and/or the Skagit County Health Department. I give my permission for any necessary treatment to be given in the event of illness or injury. I understand that all volunteers will be required to provide proof of immunity to Measles, Mumps and Rubella. A valid vaccination record showing two MMR vaccinations or blood work that shows immunity evidences proof.
Applicant's Name
Applicant's Birth Date (Minimum Age for Volunteering is 16.)

MonthDayYear
Date
Parent's Signature

Clear
Parent's Print Name
Today's Date

MonthDayYear
In the event of my child's illness, injury or emergency, please contact:
Name
Phone
Name
Phone
Should be Empty:

	Monday	Tuesday	Wednesday	Thursday	Friday
8:00am-Noon
Noon-5:00pm
3:00pm-6:00pm

	Yes	No
Aggravated Murder
First or Second Degree Murder
First or Second Degree Kidnapping
First, Second or Third Degree Assault
First, Second or Third Degree Assault of a Child
First, Second or Third Degree Rape
First, Second or Third Degree Rape of a Child
First or Second Degree Robbery
First Degree Arson
First Degree Burglary
First or Second Degree Manslaughter
First or Second Degree Extortion
Indecent Liberties
Incest
Vehicular Homicide
First Degree Promoting Prostitution
Communication with a Minor
Unlawful Imprisonment
Simple Assault
Sexual Exploitation of Minors
First or Second Degree Criminal Mistreatment
Child Abuse or Neglect as defined in RCW 25.44.020
First or Second Degree Custodial Interference
First or Second Degree Custodial Sexual Misconduct
Malicious Harassment
First, Second or Third Degree Child Molestation
First, Second or Third Degree Sexual Misconduct with a Minor
Patronizing a Juvenile Prostitute
Child Abandonment
Malicious Harassment
Promoting Pornography
Selling or Distributing Erotic Material to a Minor
Custodial Assault
Violation of Child Abuse Restraining Order
Child Buying or Selling
Prostitution
Felony Indecent Exposure
Criminal Abandonment
Manufacturing of a Controlled Substance
Posession of a Controlled Substance with intent to Manufacture or Deliver
Endangerment with a Controlled Substance
Or Any of these Crimes as they may have been renamed

	YES	NO
1st, 2nd, or 3rd Degree Extortion
1st or 2nd Degree Robbery
1st, 2nd, or 3rd Degree Theft
Forgery
Or any of these crimes as they may have been renamed

	YES	NO
Domestic Abuse
Sexual Abuse
Exploitation
Abuse
Neglect
Financial Exploitation

Volunteer Application

Contact Information

Emergency Contact

Interest & Availability

Education, Experience and Background

Disclosure Statement