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. Volunteers must be 16 years of age.

**PLEASE NOTE** -

All volunteers must be able to wear a mask covering the nose and mouth at all times to be considered and have been fully vaccinated against covid-19.

Volunteer at which location

Please indicate which Lehigh Valley Health Network campus you wish to volunteer

Name and address

Please provide your complete name and address

First name:

Last name:

Middle name:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Phone number 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.

Date of birth:

* (year optional)

Age range:

Gender:

Ethnicity:

Lived in PA-last 10 consecutive years?:

Soc Security Number:

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 and this application. I will obtain two references from non-family members immediately. I also agree to complete the required TB testing, flu vaccine, covid-19 vaccination, consent to a Pennsylvania Criminal History check, Child Abuse History Clearance, Office of Inspector General & General Service Administration to assure no fraud against Medicare, Medicaid, or any other federally funded health care program, FBI Fingerprinting-(based on assignment) and attend orientation as applicable. I understand that becoming a Hospice Volunteer has additional requirements and training.

I Agree