Please complete this application form if you are interested in becoming a Augusta University Medical Center volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information

First name:

Last name:

Title:

Preferred Name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

E-mail

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however 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.

Email address:

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Demographics

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Gender:

Education:

Ethnicity:

Uniform size:

How did you hear about this opportunity?

Skills, Hobbies & Experience

List any skills, training, or hobbies pertinent to the volunteer position desired (ie...clerical, administrative, CPR).

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

* OK to call here

Cell phone:

* OK to call here

Relationship:

Employer

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

Employer name:

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Volunteer Experience

Please list previous or past volunteer experience, if applicable.

Reference

Please provide a reference other than a relative.

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

OK to call here

Cell phone:

* OK to call here

Relationship:

Contacted:

Verified:

AU Health Volunteer Agreement

If accepted into the AU Health volunteer program, I agree to:

1. Hold as absolutely confidential all information that I may obtain directly or indirectly concerning patient and staff and not seek to obtain confidential information from a patient.

2. Become familiar with the organization's policies and procedures and uphold its philosophy and standards.

3. Donate my services to the organization without contemplation of compensation or future employment.

4. Be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others and strive to make my work professional in quality.

5. Attend orientation and in-service training as scheduled.

6. Carry out assignments and seek the assistance when necessary.

7. Take any problems, criticism or suggestions to my area supervisor or to the Office of Volunteer Services & Community Engagement.

8. Work a specified number of hours on a schedule acceptable to the organization and me.

9. Adhere to the department's sign-in policy.

10. Notify my assigned placement area if unable to volunteer as scheduled.

11. Volunteer in assigned area for a minimum for six months, at a minimum of one 4-hour shift per week. Failure to donate my services for six months or less than 100 hours will not qualify to receive a letter of recommendation or a letter of hours from Volunteer Services.

12. Return my badge and uniform to the Office of Volunteer Services and Community Engagement at the end of my service.

12. I understand that the Office of Volunteer Services & Community Engagement reserves the right to terminate my volunteer status as a result of: (a) failure to comply with organizational policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance or (d) any other circumstances which, in the judgment of the department director, would make my continued service as a volunteer contrary to the best interests of the organization.

I have read each of the preceding statements and I agree to abide by them.

I Agree