Please complete this application form if you are interested in becoming a Volunteer at St. David's Medical Center located at 919 East 32nd Street. Once the form is complete, click the submit button at the bottom. You will receive an email confirmation stating your application has been received. If you do not receive a confirmation, please contact the Volunteer Service Office at sdmc.volunteers@stdavids.com. Thank you.

Personal Information

First name:

Last name:

Preferred Name:

Date of birth:

Why do you want to volunteer at St. David's Medical Center? What attracted you to our volunteer program?

Address & Contact Information

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Cell phone:

Email address:

Education Information

Education:

Major / degree:

Name of School:

Healthcare Field of Interest:

Availability

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

Assignment Preference

Please indicate which departments you would be interested in volunteering with.

Assignment Preference:

Skills & Interests

Please identify any skills you have at least 2 years of professional or volunteer experience in and would be willing to share.

References

Please indicate two (2) people other than relatives who would be willing to serve as a personal reference.

1

2

First name:

Last name:

Cell phone:

Email address:

Relationship:

Please describe/list any other organizations that you have volunteered with. What have you enjoyed about these experiences?

Background Information

It is the policy of St. David's Medical Center to conduct investigative consumer reports (background check) on all potential volunteers, including minors. Please answer the following question: including misdemeanors, felonies, and deferred adjudications. Answering yes does not automatically disqualify you from volunteering. There is no limit to the number of years your record is searched. Have you ever been convicted of a crime?

Answer:

If you answered yes, please explain. List dates, place, and nature of any such convictions.

Emergency Contact

In the event of an emergency, please indicate who we should contact.

First name:

Last name:

Cell phone:

Relationship:

I UNDERSTAND THAT IF ACCEPTED AS A VOLUNTEER, I agree to conform to the same high standard of behavior as the professional staff and to abide by all rules and regulations set forth by the Volunteer Services Department. I agree to abide by the Policies and procedures of the hospital and the Volunteer Services Department. I understand and agree that in the performance of my duties I must hold any and all medical information in confidence. I also understand and agree that any violation of confidentiality of this medical information may result in punitive and disciplinary action.

Your agreement below indicates your approval for us to check references. The Volunteer Services Department is not

obligated to provide a volunteer position, nor are you obligated to accept any position offered.

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, gender, or disability.

I understand that St. David’s HealthCare Partnership’s policy prohibits the possession, sale, transfer, manufacture, or use of alcohol or drugs by volunteers while volunteering or while on St. David’s HealthCare Partnership property. St. David’s HealthCare Partnership policy also prohibits volunteers from being “under the influence” of alcohol or drugs while on duty.

I understand that St. David’s HealthCare Partnership will conduct an investigation of my background, including but not limited to my qualifications, education, criminal convictions, prior record and suitability for volunteering. Information regarding criminal convictions, if relevant to volunteering, may affect the appointment decision. I release St. David’s HealthCare Partnership from any and all claims, demands, actions, liabilities and damages of whatever kind regarding reference and background checks. I further authorize any and all third parties to provide reference and background information and release them from any and all claims, demands, actions, liabilities, and damages for such.

All of the information provided by me on this application form, and on any attachments, is true, correct and complete. I understand that false, misleading, inaccurate, or incomplete information on this application form, on any attachments, during interviews, or during any other aspects of the application/scheduling process will result in the rejection of my application or termination of volunteer status, if discovered after the volunteer process is completed.

I understand I will not be paid for my services as a volunteer.

I Agree