Please complete the volunteer application form for consideration into University Health Volunteer program. Once you complete the form, click the submit button at the bottom. We do not accept court appointed referrals.

Name and Address

Fill in your full legal name below. This information will ensure the accuracy of processing your background check as part of the volunteer application process.

First name:

Last name:

Middle name:

Title:

Alias:

Street Address:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

Email address:

Personal Information

Enter your valid Social Security number for identifier purposes. Applications without a valid Social Security number will not be processed. Our Volgistics database has security measures in place to keep your information safe.

Date of Birth:

Age:

Gender:

Social Security #:

T-Shirt Sizes:

Education Information

Please submit proof of current school enrollment to the University Health Volunteer Services.

Education:

CPR Certifed:

School Information:

Course of Study:

Please explain your education objective, expected graduation date.

Additional Information

How did you learn about our University Health Volunteer Program? Please name the source.

If never employed by University Health, please put N/A under employee ID# box.

University Health Employment History:

University Health Employee ID #:

Referral Source:

Contact in Case of Emergency

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

University Health Programs

Please check the following University Health programs you have participated in:

Availability

Please check volunteer availabiltiy and location preference. The approved volunteer time is 8:30am-5:00pm Monday -Friday at University Hospital.

Skills

Please check skills which you would be willing to share as a volunteer with University Health.

References

Please provide us with two references (employer, volunteer manager, etc.). Please indicate any volunteer work experience and provide your supervisor’s name and information.

1

2

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Volunteer Interest

What department or tasks are you interested to perform as a volunteer? Or, Department or tasks you are not interested in performing as volunteer?

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however we will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

What kinds of email would you like to receive?

Volunteer Opportunities

Volunteer Updates

Schedule reminders

Checklist reminders

Application Disclosure

Your date of birth is requested only for the purpose of obtaining a consumer report. Your response to the requested information is voluntary, and refusal to provide the information will not subject you to any adverse treatment. Your assistance in providing the information on this form will be greatly appreciated and will be kept confidential. Please be advised that this form will be separated from, and is not a part of, your official application for volunteer acceptance.

Note: A consumer report may consist of employment records, education verification, licensure verification, driving history, previous address, and other public records relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are applying.

I have read the above notice and understand what it means. I hereby authorize the procurement of a consumer report for volunteer purposes. Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with your application for acceptance.

If you are denied, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights.

Volunteer Application Acknowledgement

I HEREBY CERTIFY that all the information provided on this application is true, correct and complete. I grant University Health permission to verify this information for the purpose of determining my volunteer acceptance. I understand any misrepresentation or omission of any facts necessary to make this application complete shall be cause for rejection of the application or dismissal by University Health.

I understand this application is not intended as a job offer or a contract for any specific time period and that I may resign or be terminated at any time without notice or requirement of cause.

I understand and agree that, as a condition of acceptance, I will be required to successfully complete all acceptance requirements. I further agree to abide by all rules, regulations, and policies of University Health if accepted. I understand any acceptance is contingent upon successful completion of background check and health screening. I understand, if accepted, I will be required to complete an annual health screening.

Notice of Controlled Substance and Nicotine Testing Policy:

University Health conducts its operations with the highest possible degree of safety for acceptance. Because of this standard, University Health requests that all final candidates for acceptance undergo screening for controlled substances and nicotine.

The screening for controlled substance and nicotine will not be performed without the written, signed consent of the volunteer. A volunteer who decides not to submit to a screening for controlled substances and nicotine, or who does not successfully complete this screening, will not be further considered for acceptance.

By clicking I Agree, I am accepting the conditions and requirements as stated in the Volunteer Acknowledgement and Application Disclosure statements listed above.

I Agree