Adult Volunteer Application Form

Thank you for your interest in volunteering at St. Vincent's Medical Center, part of Connecticut's Hartford Healthcare network.

Please complete all required fields below to establish your applicant profile and apply for a volunteer position.

Applications are reviewed by our Volunteer Manager in a timely manner.

Application Information

First name:

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Last name:

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Street 1:

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Street 2:

City:

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State:

* Zip: *

Home phone:

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Cell phone:

*

Email address:

*

Birthday:

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Emergency Contact Information

First name:

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Last name:

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Home phone:

*

Cell phone:

*

Relationship:

*

Education information

Education:

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School:

*

Current/Most Recent Employer Information

Current/Most Recent Employer:

*

Position Held:

*

Supervisor Name:

*

Work phone:

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Volunteer Experience

Additional Employer Information

Hartford Healthcare Employment:

*

If yes, please select your facility:

How did you hear about our program?:

*

Daily Availability

Please indicate your availability for this commitment.

Assignment Preference

Please choose one or more of the four following categories:

Behind the Scenes- assist staff with clerical duties, such as filings, mailings, phone work, deliveries, etc.

Customer Service- assist patients and visitors navigating the hospital, greeting, escorting, working in our Gift Shops

Patient Support- assist patients and staff on units such as transporting, sanitizing, provide blankets/water, etc.

Wellness Programs- Pet Therapy, Meeting Facilitator, Special Needs School Program, etc.

Please list any of your preferences, from the list above, in the box provided.

Applicant's Signature

Please sign and date this form with your full name below to acknowledge and agree with the following statements:

I am over the age of 18. I am NOT a High School Student
I understand incomplete applications will not be considered for processing.
I understand that documentation of a COVID vaccine and booster shot (as soon as you are eligible), a MMR vaccine, a TDAP vaccine, history of chicken pox or varicella vaccine, and a recent tuberculosis (PPD) test will be required to volunteer at St. Vincent's Medical Center. (PPD test can be administered at SVMC.)
I understand that a flu vaccine is required in season.
I agree to abide by the policies and regulations of St. Vincent's Medical Center and the Volunteer Services Department and to participate in orientation and training required by the Medical Center.
I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients or personnel and not seek to obtain confidential information from a patient.
I understand that I may be dismissed from my duties if I fail to comply with hospital policies and procedures, willful wrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or any other circumstances deemed contrary by the Manager of Volunteer Services to the best interests of the hospital.
I authorize Hartford Healthcare to take my photograph in relation to my volunteer position.

Signature:

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Date:

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Applicant's Statement

I certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand and agree that submitting this application form does not automatically register me as a St. Vincent's Medical Center volunteer.

I Agree