Volunteer Application Form

Volunteer Application
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
TeenAge Volunteer (grades 9-12)College StudentsACOM Volunteer (OMS1 or OMS2)Adult Volunteer Program
9th Grade (Last 9 weeks)10th Grade11th Grade12th Grade
School Attending:*
List any schools clubs, extra-curricular activities, and any honors you have received:
List career fields you are interested in:
Name of parent/guardian:*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Other Emergency Contact:*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
List any medical conditions or allergies we might need to be aware of:
References

Please complete the information below and provide the NAME, EMAIL and PHONE of two (2) people who can provide us a reference for you. Note: A reference form will be emailed to each person listed.
Reference 1 (example: teacher, counselor or coach)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 (example: teacher, counselor or coach)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
NoYes
If yes, please provide name, relationship and department:*
How did you hear about the volunteer program?
Write a statement on why you wish to be a TAV:*
I acknowledge and agree to the above
Note: Health screening is done free of charge.
Work Experience (last two (2) employers)
Employer 1
Job Title
From

MonthDayYear
To

MonthDayYear
List of Duties
Employer 2
Job Title
From

MonthDayYear
To

MonthDayYear
List of Duties
Education/Skills
Education
Accounting/ClericalComputer/Data EntryCustomer ServiceTelephone
Please list any prior volunteer experience:
How did you hear about the volunteer program?
Questionnaire
NoYes
If yes, please provide name, relationship and department:*
NoYes
If yes, when and what department:*
NoYes
If yes, where and what department:*
NoYes
If yes, which area?*
I acknowledge and agree to the above
Note: Health screeing is done free of charge.
In case of emergency contact
Name:*
Relationship:*
Phone Number:*
Format: (000) 000-0000.
References

Please list two (2) references (personal or professional) other than family members:
Reference 1:*
Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2:*
Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
NoYes
If yes, please list type of offense:*
Date of Conviction:*

MonthDayYear
City and State:*
Note: A conviction does not necessarily bar you from volunteering. Southeast Health performs a criminal background check on employees as well as its volunteers. I understand that if I falsify information on my application it will disqualify me from consideration for volunteer service.
Authorization to Release Information
I acknowledge and agree to the above.
Volunteer Confidentiality Statement
As a volunteer at Southeast Health, I may be exposed to patient information as well as information regarding hospital employees. I hereby agree to maintain the confidentiality of all such information obtained during the discharge of my duties as a volunteer at the hospital. I further agree to refrain from disclosing any confidential information to third parties, except as authorized by the governing board of the hospital or as required by law. I understand that my breach of this agreement contained herein or my unauthorized disclosure of any confidential information could result in my termination as a volunteer at Southeast Health.*

I acknowledge and agree to the above.
Probationary Period of Service
It is the policy of Southeast Health that all new volunteers serve a probationary period of at least ninety (90) days from the initial date of service. The probationary period is considered a test period to help determine whether the volunteer and the service area are suitable for each other. At the end of the 90 day probationary period, the Director of Volunteers may recommend that the volunteer become a full time volunteer. If the Director is unable to recommend making the individual a regular volunteer (based on job performance or any other reason), the volunteer will be terminated from the volunteer program. At any point during the probationary period, the volunteer may be dismissed if it is determined that he/she is unable or unwilling to perform his/her duties satisfactorily or if for any other reason he/she is found to be unsuitable for continuing to volunteer at the Medical Center. If accepted, following the interview, I hereby agree to devote at least 6 months to volunteering at Southeast Health.*

I understand the policy as outlined above.
Thank you for your interest in the Volunteer Program!

Please select submit to complete your application.
Should be Empty:

Volunteer Application

References

Work Experience (last two (2) employers)

Education/Skills

Questionnaire

In case of emergency contact

References

Authorization to Release Information

Volunteer Confidentiality Statement

Probationary Period of Service