Thanks for your interest in volunteering at The University of Vermont Medical Center. Please submit this application and we will notify you regarding next steps.

Personal Information

First name:

Last name:

Middle name:

Title:

Pronouns:

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

Email address:

Physician's Name:

Physician's Phone:

Demographic Information

Date of birth:

* (year optional)

Are you over 18?:

Are you a UVMMC retiree?:

Are you a UVMMC employee?:

How did you hear about volunteering?:

Highest Level of Education:

Employment History

Please list 1 recent employer or leave blank if you have no employment history.

Current Employer:

Current Occupation:

First name:

Last name:

Work phone:

OK to call here

Interests

Please select all areas of interest.

Qualifications

Please check all applicable areas.

Availability

Please indicate the days and times you are available to volunteer. Volunteers are expected to make a 6 month commitment and work a minimum of 4 hours each week.

Emergency Contact Information

Please list one emergency contact.

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Agreement

In being considered for a volunteer position at The University of Vermont Medical Center, I agree that The University of Vermont Medical Center and any references provided at the time of my interview may exchange information about my qualifications without incurring any liability.

Acceptance for volunteer placement is subject to:

1. Satisfactory reference and screening reports.

2. Personal interview with the Director of Volunteer Services or the Program Coordinator.

3. Willingness to abide by all organizational requirements and regulations.

I understand that The University of Vermont Medical Center is not obligated to provide placement, nor am I obligated to accept a position. To the best of my knowledge, the information provided in my application is true and complete. I understand that any misrepresentations or omissions of facts shall be considered sufficient cause for dismissal.

I Agree