Please complete this application form if you are interested in becoming a Mon Health System Volunteer. Once you complete the form, click the submit button at the bottom.


APPLICANT


EMERGENCY CONTACT


CURRENT EMPLOYMENT (if applicable)


PRIOR VOLUNTEER EXPERIENCE


AVAILABILITY

Please check all that apply and list times where applicable.



OTHER


OTHER


OTHER


REFERENCES (you may not use relatives)


MON HEALTH SYSTEM AGREEMENT

Believing that Mon Health System has need of my services as a Volunteer worker, I agree to: Hold as absolutely confidential ALL information which I may obtain directly or indirectly concerning patients, doctors or personnel and I will not seek out confidential information in regard to a patient. My services are donated to Mon Health System without contemplation of compensation or future employment and given with humanitarian or charitable reasons.


Opportunities for Volunteers are provided without regard to religion, creed, race, national origin, age, sex or disability.


NOTE: Filling out an application does not assure placement, since the number of applicants usually exceeds the number of available openings. Applicants will be chosen on the basis of qualifications in keeping with the best interest of the Mon Health System.


The first month of Volunteer experience will be mutually probationary. All applications will be kept on file for (90) days.


An offer to volunteer in positions at Mon Health System will be contingent upon a criminal background check at the county, state, and federal level. In addition, a reveiw of the Department of Health and Human Services (DHHS) Office of Inspector General's (OIG) list of individuals excluded from participation in Medicare, Medicaid, and other federal health programs will be conducted. If the results of the background check indicate evidence of an arrest or conviction for a crime that could place Mon Health System, patients, and/or co-workers at risk, your ability to volunteer may be prohibited. Volunteering at Mon Health System is prohibited for any individual on the DHHS OIG list of excluded indiviudals.