Volunteer Application

Thank you for your interested in volunteering at Williamson Medical Center. Please review the requirements below, complete the application, and click the submit button when your application is complete. The fields marked with an "*" are required.

Volunteer Requirements:

Volunteers must:

-be 14 years or older

-be willing to make a minimum commitment of one two hour shift per week with a minimum of 12 hours per month.

-complete all pre-volunteer requirements and attend a mandatory Volunteer Orientation to be scheduled upon acceptance to the volunteer program.

ALL APPLICANTS SHOULD CONSIDER THE FOLLOWING:

1. Are you involved with other organizations, hobbies, work commitments, sports, or have a changing academic schedule that might prevent you from keeping your commitment?

2. Will your schedule allow you to volunteer for three months with no more than two absences?

3. Are you available to volunteer once a week, same day and same time every week?

4. Do you have consistent transportation?

5. Are you mature, responsible, outgoing, friendly, proactive and willing to engage people as you assist them?

Personal Information

Background Information

Have you been convicted of a crime?:

If yes, describe in full, including dates:

Education

Highest Level of Education Completed:

Major/Degree:

Currently attending school? Where?:

Expected graduation date:

Employment History

If you have worked in the last five years, please provide information about your employment history.

Former or Current Occupation:

1

2

Employer name:

City:

State:

Have you been employed or volunteered with Williamson Medical Center in the past? If yes, state final position held, termination date and reason for leaving:

Previous Volunteer Experience

If you are currently volunteering or have volunteered for other organizations, please describe your volunteer experiences, length of service and responsibilities.

Skills and Experiences

Help us learn a little more about yourself. Please identify any skills or experiences you have.

Assignment Interest

Please choose two areas that interest you.

Experience with Children

If you are interested in volunteering with children, please tell us about your experience(s) working with children. Have you worked or volunteered with children who are/were ill? How did you maintain professional boundaries?

Volunteer Availability

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

References

Please list two references. Please do not list relatives as your references.

1

2

First name:

Last name:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Email address:

Emergency Contact Information

Please list the name and phone number of the person you would like contacted in the event of an emergency.

1

2

First name:

Last name:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Email address:

Relationship:

Volunteer Pledge and Waiver

Understanding that Williamson Medical Center has a valid need of my services as a volunteer:

* I will be punctual and conscientious in the fulfillment of my duties and accept supervision graciously.

* I will consider as confidential, all information which I may hear directly or indirectly concerning a patient, physician, nurse, or any other person related to the hospital. I will not seek information in regard to a patient.

* I will take any problems, criticisms, or suggestions to the Volunteer Coordinator.

* I will endeavor to make my work professional in its quality.

* I will conduct myself with dignity, courtesy and consideration.

* I will represent the Volunteer program in a positive manner by practicing service excellence, respecting all others, smiling, and using appropriate behaviors at all times.

---------------------------------------------

I certify the above statements are made truthfully and realize falsification may result in dismissal. I understand that this application does not guarantee a volunteer placement.

The undersigned volunteer agrees to abide by all Williamson Medical Center rules and regulations. Permission is granted to this Medical Center to investigate references and criminal background. I release from liability or responsibility all people, places of business and municipalities supplying such information. I understand my volunteering will be subject to a satisfactory investigation report, satisfactory check of my references and the satisfactory post-medical screening, and my volunteering may be terminated by either party at will upon notice to the other.

I Agree