Our vision is that your insights will help to identify what really matters most to our patients in their health care experience. Together we will improve quality, safety and the patient experience.


Name and address


Employment History

What is your current employment status?



Demographic Information


Emergency Contact


Services Received

Within the last three years, what care services have you or your family member used?



Care Provided At

At which location have you received services?



Life Experiences

Please share about your skills, talents, hobbies and/or interests.



Strengths

What strengths will you bring to this role?



Challenges

What do you think may be challenging for you?



Your Objectives

What would you like to gain from this experience?



Work or Volunteer History at Virginia Mason

If you have worked or volunteered with us before, when and in what capacity?



Other Considerations

Are there any other considerations that may influence your volunteer placement?



Email Communication Agreement

I agree that Virginia Mason may use email to communicate with me regarding my volunteer service. I understand that email is not a secure medium for sending and receiving potentially sensitive personal healthcare information. Virginia Mason cannot assure the confidentiality or protection of email communications, particularly if the emails are sent to multiple individuals participating in volunteer services. In addition, email sent to Virginia Mason may be accessed by individuals who are not directly involved in Volunteer Services (for example: by my employer if my email address is provided, by my internet service provider).