Online Volunteer Application

Thank you for your interest in volunteering with Sauk Prairie Healthcare! If you are interested in becoming a volunteer, please complete this form and click the submit button at the end. When your application is received, you will be contacted to schedule an interview, and additional forms will be provided. Prior to receiving a volunteer assignment, all volunteers are required to consent to a criminal background check and undergo our medical clearance process including completion of a Health Record form, immunization review and tuberculosis screening. Volunteer applicants between the ages of 14 and 18 years old must submit a parent/guardian consent form as well. If you have questions about our volunteer program or this application, please call 608-643-7257 or email volunteers@saukprairiehealthcare.org. Thank you!

Personal Information

First name:

Last name:

Middle name:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Birthday:

Briefly describe why you are interested in volunteering with SPH:

Parent/Guardian Consent

If you are under age 19, please give a parent/guardian's name and contact information (phone/email):

References

Please list two personal or professional references. Please do not include relatives.

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2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

Please indicate each reference's relationship to you.

Education

If you are currently a student, please indicate school and grade level:

Work Experience

Employment Status:

Please list your current or most recent employer, if applicable.

Volunteer Experience

Please indicate other volunteer work you have done:

Recruitment

How did you find out about the need for volunteers at Sauk Prairie Healthcare?

Availability

Please indicate the days and times you are usually available to volunteer.

Background Information

Have you ever been convicted of a crime other than minor traffic violations? If no, enter "none" below. If yes, please describe and indicate dates. Note: A conviction record will not necessarily disqualify you from volunteer consideration. A background check is required prior to volunteer assignment.

Skills & Interests

Please indicate skills you would like to share with us (i.e. clerical skills, customer service, retail, etc.)

Assignment Preference

Below is a list of example volunteer assignments. Please indicate in the box below which assignments interest you, or give an example of what you'd like to explore further as a volunteer role.

Clerical: Basic clerical tasks in office or clinic setting.

Department Delivery: Sort, pick up and deliver office mail.

Emergency Department: Provide non-medical support, rounding on patients, visitors and staff in the Emergency Department.

Gift Shop: Cashiering/Stocking

Patient Visits/Hospitality Cart: Visit patients and provide complimentary coffee to guests.

Mobile Meal Delivery: Deliver meals to homes during the week.

Patient Care: I prefer a role where I can interact with patients.

Non-Patient Care: I prefer roles behind the scenes, not interacting with patients.

Pet Therapy: Must be registered with Dogs On Call or Alliance of Therapy Dogs.

Pharmacy: Sort, label, assemble, collate and assist staff with projects.

Surgery Center Liaison: Interact with patients' families in the surgery center.

Welcome Desk Escort Transport: Escort and transport people and items around the hospital as requested.

Yardwork: Weeding, watering and planting in the gardens at the Wellspring Campus.

Other: Please indicate other interests.

Emergency Contacts

In the event of an emergency, whom should we contact?

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2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Cell phone:

Relationship:

Volunteer Application Agreement

I understand and agree that submitting this application form does not automatically appoint me as a Sauk Prairie Healthcare volunteer.

By submitting this form, I certify that all information I have supplied is true, accurate and complete. I understand that any misrepresentation or omission of fact in this application may result in denial of volunteer opportunity. I understand that I will be performing services as a volunteer without compensation.

I understand the information I have provided in this application form may be verified to assess my suitability for volunteerism, including contacting persons named in this application as references, and by conducting a criminal background check. I authorize Sauk Prairie Healthcare to obtain a criminal background record check from a third party administrator and consider such reports when making decisions about my volunteer application.

It is the policy of Sauk Prairie Healthcare to consider all applicants for the volunteer program without regard to age, race, color, creed, religion, disability, marital status, gender, sexual orientation, national origin, ancestry, arrest record, conviction record, veteran's status, membership in the National Guard, state defense force or any other reserve component of the military forces of the United States or Wisconsin, or any other unlawful basis.

I understand and agree that, in the performance of my duties as a volunteer at Sauk Prairie Healthcare, I must not repeat anything I see or hear to anyone. This includes information about patients, their families, hospital procedures or staff performance. Further, I understand that intentional or involuntary disclosure of confidential information may result in immediate dismissal as a volunteer and could also result in being sued.

Thank you for completing this volunteer application form and for your interest in volunteer opportunities with Sauk Prairie Healthcare. We will contact you soon regarding the status of your application.

I understand that by checking the "I Agree" button below, it serves as my signature and signifies that I have read and accept all terms of the foregoing statement.

I Agree