Applicant Name and Address

First name:

Last name:

Middle name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Site Selection

Please communicate your preference on whether you would like to volunteer at Mountain Vista, Florence Hospital, Tempe St. Luke's Hospital or St. Luke's Behavioral Health, Phoenix.

Volunteer Type

Volunteers must be at least 16 years of age to volunteer. If you are age 18 or older, please mark adult. If you are age 16 or 17, please mark junior.

Type:

Emergency Contact

Please list at least one emergency contact.

1

2

First name:

Last name:

City:

State:

Home phone:

Cell phone:

Relationship:

Work Experience

Please list your work experience, including any special skills you have developed.

Volunteer Experience

Please list any volunteer experience you have had in other places.

Skills, Abilities and Languages:

Please list skills, abilities and languages you possess that you would believe would benefit you as a volunteer.

How Did You Hear About Us?

Please tell us how you learned about the Volunteer program?

How did you find us?:

Please tell us how you learned about the Volunteer Program.

Availability

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

Have you ever been convicted of a crime?

If yes, please explain.

Agreement

*I am age 16 or 17 (high school student) and agree to complete a minimum of 40 hours per semester. -OR-

*I am a college student, age 18 or older and want to volunteer in the Hospital at least two four-hour shift per month and complete a minimum of 100 hours with in a year. -OR-

*I am age 18 or older and want to volunteer in the Hospital at least one four-hour shift per week for a period of at least one year (with time off as needed).

I am available Monday-Friday between the hours of 8:00 a.m.-4:30 p.m. for an interview and, if selected as a volunteer candidate, for on-site screening, scheduling, classroom training and on-the-job training.

I authorize the Hospital to conduct and evaluate the results of a Reference Check, Background Check, Health Screen, Drug Screen and TB Skin Tests as a condition of my acceptance for volunteer service.

I agree to participate in Training, including New Volunteer Orientation, Job-Specific Instruction, Annual Update Training and inservices determined necessary by the Hospital.

I agree not to discuss or divulge Confidential Information I may learn about the Hospital¡¦s business, staff, patients, visitors, volunteers or other associates.

I agree to abide by all Policies and Procedures of the Volunteer Services Department, the Hospital and Steward Healthcare Corporation.

I understand that the Identification Badge and any Key issued to me is the property of the Hospital, and I agree to return it (them) upon leave of absence, termination of volunteer service or whenever requested by staff to do so.

I Agree