Clone of Student Volunteer Program Application Packet

Auxiliary Membership Application Packet

Bay Area Hospital
Dear Community Member,

We are excited that you are interested in volunteering at Bay Area Hospital! Volunteers are the heartbeat of our hospital, providing invaluable services and support to our patients.

Included in this packet for your completion and signature is the Auxiliary Application. Your application will be submitted electronically at the end of this application form, once you hit the "Submit" button.

What Happens Next? Once we receive your application, we will contact you to schedule a tour and interview. After the interview, if you are accepted into the Auxiliary, we will need to schedule two Employee Health appointments for you. This is required for all healthcare workers, so it is good practice. You will go through TB screening and complete another packet of forms. Once you clear employee health, you must attend a two-hour Volunteer General Orientation, which will cover the BAH Auxiliary Volunteer Guide in detail. All volunteers must be interviewed prior to starting and agree to pay a $10 annual fee to offset nominal program costs.

Volunteers provide valuable services to the hospital and our community. We appreciate your interest in volunteering.

Volunteer Services Coordinator
Bay Area Hospital
1775 Thompson Road
Coos Bay, OR 97420
(541) 269-8135

Volunteers@bayareahospital.org

CONTACT INFORMATION
Full Legal Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Best Phone Number to reach you:
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT(S)
Personal (non-family) Reference and a Physician Reference:
Any Physical Limitations?
Enter any limitations you might have
8:00am to NoonNoon to 4:00pm
MondayTuesdayWednesdayThursdayFriday

INTERESTS & PREVIOUS EXPERIENCE
Previous Work Experience
List your interests
YESNO
If yes, please indicate when:
Previous Volunteer Experience
Summarize your previous volunteer experience.
Education or Special Training
Summarize your previous volunteer experience.
Hobbies, Skills, Special Interests, Organizations to which you belong
Summarize your previous volunteer experience.
YESNO
List other languages spoken:
CRIMINAL BACKGROUND
YESNO
If yes, please list Charge, Charge Date, County, City, State
YESNO
If yes, please list Charge, Charge Date, County, City, State
AGREEMENT & SIGNATURE

I authorize release of all educational records, employment information and/or personal references from any school, company/agency or person listed above. The information that I have provided on this application is true and complete to the best of my knowledge.
Enter Printed Name
General Agreement Signature
Date

MonthDayYear
Today's Date
RELEASE

It is the policy of Bay Area Hospital to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in volunteering at Bay Area Hospital.
CONSENT FORM for VOLUNTEER PROGRAM
Name:

First NameLast Name
I agree to participate in Bay Area Hospital’s volunteer program. I agree to read the literature that is provided to me so that I will understand the expectations.

I understand that I am required to have a Tuberculosis Test and a Criminal Background Check and I give my permission for these tests to performed. I further understand that if I do not pass the Criminal Background Check, I will be dismissed from the program.

I am aware and acknowledge that during the course of my duties, I might view medical procedures, surgeries, and births. The records are subject to the strictest of confidentiality according to HIPAA Privacy laws.

I understand that it is my responsibility to find or provide transportation to and from my assignments. I agree to notify the appropriate person in advance if unable to work and that several absences may be grounds for dismissal from the program.
Signature of Participant
Date

MonthDayYear
Today's date
Should be Empty:

Auxiliary Membership Application Packet

CONTACT INFORMATION

INTERESTS & PREVIOUS EXPERIENCE

CRIMINAL BACKGROUND

AGREEMENT & SIGNATURE

RELEASE

CONSENT FORM for VOLUNTEER PROGRAM