Thank you for your interest in Hennepin County Medical Center's Emergency Department (ED) P.E.E.R. Volunteer Program.

Please complete the following application form. A valid email address is required to complete this online application and will be used as a communication tool in the application process. Your email address is kept confidential.

All (*) lines are required fields. Once complete, hit submit at the bottom of the page.

Please complete the following steps to begin your application with the HCMC ED P.E.E.R. Volunteer Program:

Please send all application materials and forms, besides references, in one email to Gina (gina.kalkar@hcmed.org) and Ojaswini (ojaswini.thodupunoori@hcmed.org). We will only consider completed applications with all components sent in ONE email, not separate emails.

1). Application

IF YOU SUBMIT THE BACKGROUND CHECK WITHOUT THE APPLICATION, YOUR APPLICATION WILL NOT BE CONSIDERED.

2). Background Study

IF YOU DO NOT SUBMIT APPLICATION WITH THE BACKGROUND CHECK YOUR APPLICATION WILL NOT BE CONSIDERED.

3). Required Health Screening Information

Print out and take with you to your Health Screening at Boynton Health on campus or a clinic of your choosing. Please mail your health screening to:

ED PEER Coordinator

Hennepin County Medical Center

701 Park Avenue, Mail Code R2

Minneapolis, MN,55415-1829

4). Two references (form found on the ED P.E.E.R webpage). Please email your

references to two recommenders and have them email the forms back to:

edpeercoordinator@hcmed.org , ojaswini.thodupunoori@hcmed.org , gina.kalkar@hcmed.org

Once your application is complete, we will send you confirmation that is has been received. You will later be contacted regarding a brief interview.

Please e-mail us at edpeercoordinator@hcmed.org, ojaswini.thodupunoori@hcmed.org , gina.kalkar@hcmed.org with any questions.

Again, we appreciate your willingness to serve our community and hope that you have a valuable volunteering experience.

Sincerely,

Gina and Ojaswini

The ED P.E.E.R. Program Coordinators

Application

The application is the first step in the process. Please fill out the application in it's entirety and hit submit at the bottom of the page.

First name:

Last name:

Middle name:

Street 1:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

Email address:

State of Minnesota Background Check

The Background Check is the second step in the process. Please submit that form immediately. You will receive a BLUE LETTER from the State of Minnesota stating that you have passed. This letter will also come to us automatically, but this takes a little bit of time.

Health Screening

Your Health Screening is due to us by the application deadline for each session. For U of M students, we recommend Boynton Health on campus or another clinic of your choosing. Other students, check with your campus health department. Please bring your forms with you to your appointment, found under additional forms tab on home page.

References

Please email the references to 2 people. Have them complete and email the forms back to:

edpeercoordinator@hcmed.org

or mail to ED PEER Coordinator address as listed on website.

Demographic Information

Fill in the following information. * indicates a required field. If you are not a MN resident, you can leave the drivers license field blank.

Date of birth:

Gender:

Education:

Diploma/Degree completed:

Ethnicity:

School:

Social Security Number:

Referral Source:

Work Experience

Please briefly list your previous work history, indicating the location, position and duration.

Please briefly list your previous work history:

Volunteer Experience

Please briefly list your previous volunteer service, indicating the location, position and duration.

Please briefly list your previous volunteer expereince:

Emergency Contact

Please list one person and their primary phone number, that we could contact on your behalf in case of an emergency.

First name:

Last name:

Home phone:

Cell phone:

Relationship:

Personal Goals and Expectations

Why do you want to be involved in this program and what are your expectations?

What are your goals related to being involved in the HCMC ED P.E.E.R. program?

What are your goals of being involved in the HCMC ED P.E.E.R. program?

I agree

I agree that information on this application is correct. I understand that it is my responsibilty to also submit two references, the required health screening information as well as the additional 5 forms. I understand that I will not be considered for the HCMC ED P.E.E.R. program until all necessary paperwork has been submitted as well as this online application.

I Agree