Volunteer Application Form

Thank you for your interest in becoming a volunteer at Lehigh Valley Health Network. When you complete the application form, click the submit button at the bottom. If you are selected as a volunteer, you are agreeing to perform a minimum of 50 hours of volunteer service.

**PLEASE NOTE** -

This application is for adults only. Areas of volunteering are limited at this time. We are offering non-patient facing volunteer opportunities only. All volunteers must be able to wear a mask covering the nose and mouth at all times to be considered.

Volunteer at which location

Please indicate at which Lehigh Valley Health Network campus you wish to volunteer, i.e. LVH-Cedar Crest & I-78 (Allentown), LVH-17th & Chew Streets (Allentown), LVH-Muhlenberg (Bethlehem), Hospice, LVH-Tilghman, or Mack Builiding (no patient contact)

* Assignment Preference:

Name and address

Please provide your complete name and address

First name:

Last name:

Middle name:

Nickname:

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:

Email address

***Please use a reliable email address. Correspondence will be sent to you via email frequently.***

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.

Date of birth:

* (year optional)

Age range:

Gender:

Ethnicity:

Lived in PA-last 10 consecutive years?:

High School Graduation Year:

Veterans: please check here:

My availability is:

From:

to:

Interest in volunteering

Why do you want to volunteer?

Are you volunteering to complete a particular requirement? Example, school graduation project, court mandated community service, etc.

How did you find out about volunteer services at Lehigh Valley Health Network?

Work, volunteer, and educational experience

Please tell us a little bit about your work, education, and volunteer background. Are you currently employed or are you retired? What kind of work? Have you ever volunteered before? Where? What did you do?

High school:

College:

Are you an employee of LVHN?

If yes, please list the department in which you work.

Criminal background - REQUIRED

Have you ever been CONVICTED of a misdemeanor or felony? Yes or No

If yes, please explain

Any Convictions?:

Medical history - REQUIRED

Have you had the following diseases: Mumps, Rubella, Polio, Measles, Chicken Pox, tuberculosis

Immunization dates, if known

Have you had the above diseases?:

Emergency contact information

Please give us information on who we can contact in case of an emergency

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

* OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

How did you hear about LVHN Volunteering?

How did you hear about LVHN Volunteer opportunities and/or did someone refer you? If an individual, please list their name below so we can thank them.

Skills to share

What skills do you have that you would like to share as a volunteer? Example: customer service, computer, languages, retail/marketing, etc.

Volunteer Program Requirements

I have read the appropriate requirements of becoming a volunteer at Lehigh Valley Health Network on the LVHN.org/Volunteer webpage. I will obtain two references from non-family members immediately, complete the required TB testing and flu vaccine, purchase a volunteer uniform, attend orientation, consent to a Pennsylvania Criminal History check, Office of Inspector General & General Service Administration, FBI Fingerprinting and Child Abuse clearance (based on assignment). If accepted as an adult volunteer, I agree to perform a minimum of 50 hours of volunteering to LVHN. I understand that becoming a Hospice Volunteer has additional requirements and training.

I Agree