UPMC Volunteer and Community Services Application Form

Please complete this application form if you are interested in becoming a UPMC Volunteer and Community Services volunteer. Once you complete the form, click the Continue button at the bottom.

** DO NOT APPLY MORE THAN ONCE **

Please scroll down to the "Availability" section before proceeding, as some programs are full and not accepting new applications.

If you have volunteered at one of the UPMC facilities in the last 2 years, there is no need to re-apply. Please notify the hospital Volunteer Department in which you were a volunteer.

Contact Information

First name:

Last name:

Middle name:

Title:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

Demographic Information

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. NOTE: Age requirements may vary by location.

Type:

Date of birth:

Gender:

Highest Level of Education Achieved:

Criminal Violation(see below):

Ethnicity:

Military Status:

Major degree:

School:

Check if 15 yrs or older:

FOR PA APPLICANTS ONLY

Have you lived outside PA. in the past 10 years?

Hobbies & Skills

List your hobbies and any skills that would help you in volunteering.

This includes language skills (read, write, speak, or sign).

Availability DO NOT APPLY MORE THAN ONCE

1. UPMC Presbyterian Montefiore Hospital - If you have made arrangements to be a part of the NODA program, please continue with your application

2. Hospital Elder Life Program (HELP) at UPMC Shadyside - If you want to volunteer with HELP, select HELP as your site.

3. UPMC Passavant (McCandless/Cranberry): Passavant is no longer accepting high school student applications. The program is closed.

4. Magee-Women's Hospital: The Cuddler Program is full and not accepting applications at this time.

5. WPIC-All positions for the upcoming semester have been filled.

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

Type of Volunteer Work Preferred

List the types of work you prefer and indicate if you would like a position with patient contact.

Emergency Contact

In the event of an emergency whom should we notify?

Physician's Name:

Physician's Phone:

1

2

First name:

Last name:

Home phone:

Work phone:

Relationship:

Work & Volunteer Experience

Please list your most recent employer or volunteer experience, if applicable.

Employer name:

Reason for Volunteering

Why are you interested in volunteering?

Referral Source:

Community Service

Have you applied for volunteer service to fulfill a school or court appointed community service requirement? If yes, please include explanation along with the number of hours required.

Violations

This information is REQUIRED: Have you ever pleaded guilty, been convicted of, accepted ARD or similar program, or pleaded no contest other than a summary offense? Please Indicate Yes or No. If yes, please describe.

Citizenship

This information is REQUIRED: Are you a U.S. Citizen? Please indicate Yes or No. If you are not a citizen, Visa and/or Passport documentation are required at your interview appointment.

I Agree

I understand and agree that submitting this application form does not automatically register me as a UPMC Volunteer and Community Services volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and complete to the best of my knowledge. I understand that any false statement, misrepresentation or omission may cause my dismissal from volunteer service.

I Agree

Contact Information

Demographic Information

FOR PA APPLICANTS ONLY

Hobbies & Skills

Availability ** DO NOT APPLY MORE THAN ONCE **

Type of Volunteer Work Preferred

Emergency Contact

1

2

Work & Volunteer Experience

Reason for Volunteering

Community Service

Violations

Citizenship

I Agree

Availability DO NOT APPLY MORE THAN ONCE