Volunteer Recruitment Form

VOLUNTEER RECRUITMENT FORM

This form is the first step in becoming a volunteer with Cody Regional Health (CRH). Volunteer placement is based on service needs, and completion of required clearances. Before your first shift, all volunteers must complete: (1) background screening; (2) required state/federal screenings as applicable; (3) a Volunteer Orientation; and (4) Employee Health clearance (including TB test and vaccination documentation or declinations (declined to answer), as required). If the applicant is under 18 years of age, OR if the applicant is 18 or older and has a legal guardian, conservator, or other legal representative authorized to sign on their behalf, the Parent/Guardian / Legal Representative section must be completed and signed. (PAPER FORM AVAILABLE BY REQUEST.) For paper form, please contact Program Lead. Contact information listed at bottom of this page.
A. Applicant Information

(Will be used to conduct the state/federal screenings as applicable)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Texts
Address

Street Address

Mailing Address (if different from above)

CityState / Province

Postal / Zip Code
Email (required for background check)
example@example.com
Social Security Number (required for background check)
Please only enter numbers. No spaces, symbols, or dashes.
Birthdate (required for background check)

MonthDayYear
MM-DD-YYYY
How Did You Learn About Our Volunteer Program?

Other (Please Explain)
Are You Under 18 Years Of Age? (if yes, please complete the Guardian Information section below)
B. Emergency Contact Information

(Optional)
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
C. Parent / Guardian / Legal Representative Information

Complete section C if: (1) the applicant is under 18, OR (2) the applicant is 18 or older and has a court-appointed guardian, conservator, or other legal representative authorized to sign on the applicant’s behalf.
Full Name Of Parent / Guardian / Legal Representative

First NameLast Name
Parent / Guardian / Legal Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian / Legal Representative Email Address
example@example.com
I, the undersigned Parent/Guardian/Legal Representative, give permission to Cody Regional Health (“CRH”) to complete the required tasks for the applicant named above, including: (1) TB Testing: authorizing the CRH Employee Health Nurse to administer a tuberculosis (TB) screening test and to read/interpret the results 48–72 hours after administration; (2) Background & Database Checks: authorizing CRH and/or its designated agents to conduct all required state and federal background screenings, including criminal history and applicable database checks, as required for volunteer service; (3) Orientation/Training: granting permission for the applicant to participate in Volunteer Orientation and any required training as a condition of volunteering; and (4) Code of Conduct/Policies: acknowledging that the applicant will be required to review and sign CRH’s Volunteer Code of Conduct and related volunteer policies, and consenting to the applicant entering those agreements as part of volunteer service. I understand that volunteer eligibility may depend on completion of these requirements and receipt of acceptable results, and that failure to comply with CRH policies may result in removal from the volunteer program.
Date

MonthDayYear
Date
Guardian Signature
D. Volunteer Interests

While we will try to take your interests into account, we may not always have a need in that area at the time of your application's submission. Please select your preferred area of service and we will work with you to find the best placement.
Please Select Which Areas Of Service Interest You

Other (Please Explain)
Which Area Is Your First Choice?
Which Area Is your Second Choice?
E. Availability
Preferred Shift Length
Preferred Hours Per Week
Length of Commitment With CRH (if known)
Your Preferred Start Date
F. Skills And Training
What Skills, Training, Or Certifications Do You Have That May Be Helpful?
Do You Speak Any Languages In Addition To English? If So, Please List Them Below.
(This Question Is Optional But May Be Helpful To Know For Proper Volunteer Placement.)
G. Health, Safety, and Readiness

Cody Regional Health (“CRH”) is committed to maintaining a safe environment for volunteers, patients, and staff. Before placement, Employee Health will review all required health documentation. CRH requires each new volunteer applicant to complete a TB test and to provide documentation of COVID-19 and influenza vaccination status or complete any required declination (declined to answer) form, before acceptance into the Volunteer Program. CRH will also attempt to provide reasonable accommodation, when possible, to support a volunteer’s role, but cannot guarantee that every accommodation request can be met. The Volunteer Coordinator and Employee Health Nurse will contact you to discuss any accommodation requests prior to placement. I understand that while volunteering at CRH, I may be exposed to risks including, but not limited to, physical injury, illness, infectious disease, or other health-related exposures. I acknowledge that I volunteer at my own risk and am responsible for my own health and safety while serving in the volunteer role. I further understand and agree that if I sustain an injury, contract an illness, or am exposed to illness while on CRH premises or while performing volunteer duties, CRH may provide or arrange emergency medical evaluation or treatment through its Emergency Department in the same manner it would for any patient. I understand and agree that any costs associated with such care, treatment, evaluation, testing, or follow-up services shall be my sole responsibility.
I Understand TB Testing And Vaccination Documentation Or Declination (declined to answer) Forms Are Required Before I Can Volunteer. (select all that apply)
Do You Have Any Health-Related Limitations Or Accommodation Needs?

Yes I Do (Please Explain)
I Understand And Agree That I Volunteer At My Own Risk And Am Responsible For Any Medical Costs Resulting From Injuries, Illnesses, Or Exposures That Occur While Volunteering At CRH.
H. Consent/Background

Cody Regional Health ("CRH") may obtain information about you from a consumer reporting agency and/or other lawful sources for the purpose of determining your eligibility to serve as a volunteer and for ongoing volunteer placement, reassignment, or continued service. These reports may include a consumer report and/or an investigative consumer report as defined by the Fair Credit Reporting Act (FCRA). An investigative consumer report may include information obtained through personal interviews regarding your character, general reputation, personal characteristics, and mode of living. Scope of Screening (may include, as applicable) • State of Wyoming Department of Family Services (DFS) screening. • Criminal history searches (local, state, and/or national), including related criminal databases as permitted by law. • Sex offender registry checks (including state and national registries, as applicable). • Federal healthcare exclusion checks, including the U.S. Department of Health and Human Services Office of Inspector General (OIG) exclusion list, as applicable. • Identity verification and prior name/alias searches.
Are You Currently, Or Have You Ever Been Employed By Cody Regional Health?
If You Answered Yes To The Question Above, Please Share The Dates You Were Employed And The Reason For Separation.
Current or Previous Employment Does Not Automatically Disqualify You From Volunteer Services.
I. Background Check Disclosure & Authorizations

By signing below, I certify that the information I have provided in this application— including the identifying information collected for screening purposes— is true, accurate, and complete to the best of my knowledge. I understand that any significant misrepresentation or omission may result in denial or revocation of volunteer status. I understand that volunteering is not employment and does not create a contract for services. If accepted as a volunteer, I agree to follow Cody Regional Health (“CRH”) policies and procedures applicable to my role, maintain professional conduct, and perform only tasks assigned and approved by CRH. I understand and agree that CRH will use the information and answers I have provided in this document to submit and complete required background and eligibility screenings and to verify information as needed for volunteer program purposes. I further authorize CRH and/or its designated agents to obtain the reports and information described above for purposes of determining volunteer eligibility and making decisions related to ongoing volunteer service. I understand that CRH may share the information obtained with appropriate CRH representatives who have a need to know for volunteer program purposes, and that CRH will handle such information in accordance with applicable confidentiality and privacy practices. I understand that I may request, in writing, a copy of any consumer report obtained about me, if applicable.
Date

MonthDayYear
Applicant Signature
Thank you for your interest in volunteering at Cody Regional Health!

For questions, please contact the following individuals with Vounteer Services for Cody Regional Health:

JD Poeverlein & Trista Stout

Phone: (JD) 307-578-2567

Phone: (Trista) 307-578-2569

Email: Volunteer@codyregionalhealth.org
Should be Empty:

VOLUNTEER RECRUITMENT FORM

A. Applicant Information

B. Emergency Contact Information

C. Parent / Guardian / Legal Representative Information

D. Volunteer Interests

E. Availability

F. Skills And Training

G. Health, Safety, and Readiness

H. Consent/Background

I. Background Check Disclosure & Authorizations