Please complete this application form if you are interested in becoming a Waverly Health Center volunteer. Once you complete the form, click the submit button at the bottom.

Personal Information

Demographics

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:

Gender:

Education

Please tell us the highest level of education you completed (high school, college, post-grad) and what degree was earned.

Work Status

What is your current work status? Where is your current or last place of employment?

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Cell phone:

Relationship:

Availability

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

Criminal Background

Have you ever committed, been convicted of, pled guilty to, or pled no contest to a felony or misdemeanor? Arrests for cases still in progress WILL show up on the criminal background check. (NOTE: Conviction of a crime is not necessarily grounds for disqualification. HOWEVER, a false answer to this question WILL mean disqualification.)

You must answer yes or no. If "yes", please include an explanation

Service Area Opportunities

The following volunteer service areas may currently be available. Details on each service area are available on the WHC website. Please check all that you are interested in.

Skills & Interests

In which of these areas do you feel you have moderate to excellent skill? Check all that apply.

Additional information

Please answer the following questions.
What do you hope to gain from your volunteer experience?
Do you have any prior experience volunteering in a health care setting?

Personal References

Please list two references. Do NOT use physicians or relatives.

1

2

First name:

Last name:

Home phone:

Cell phone:

Relationship:

I Agree

I understand and agree that submitting this application form does not automatically register me as a Waverly Health Center volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

As a VOLUNTEER, I...

-agree to attend volunteer orientation and train until I am competent to perform the required duties.

-agree to comply with all the rules and regulations of the hospital and the Volunteer Services department.

-understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties outside my service guidelines.

-agree to call my staffing chairperson or volunteer services manager as soon as possible when I have schedule changes.

Confidentiality: It is the belief of this hospital that all medical, financial, and personal information pertaining to a patient is confidential and is protected from unauthorized viewing, discussion, and disclosure. Therefore volunteers may look at, use, or disclose patient information ONLY as it relates to the performance of their duties. Any unauthorized viewing, discussion, or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential, it is your responsibility to discuss the matter with your supervisor before any breach of confidentiality occurs.

I acknowledge and have read the statement above and agree to abide by the expectations of the Department of Volunteer Services and the Waverly Health Center.

I Agree