Please complete this application form if you are interested in becoming a Southwest General volunteer.


We are currently accepting volunteer applications from those who are 14 years of age and older.


Once you complete the form, click the continue button at the bottom.


Personal Information


Emergency Contact

In an emergency please notify:



Education

Please be advised that we are not able to accept seasonal placements.



Email

We like to keep volunteers informed of important news and volunteer opportunities by email, however we will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.



Employment Experience


Volunteer Experience


Special Interests

Please list hobbies, skills, special interests, clubs or affiliations.



References

You are required to submit two references. One reference must be from someone in a leadership/advisory role (i.e. teacher, clergy, counselor, employer). Relatives are not accepted as references. Students must provide a teacher or guidance counselor as a reference.



Availability

Please indicate any times that you would be able to accept a volunteer assignment. This does not commit you to multiple assignments. Because of the investment in orientation, training etc. we ask volunteers to make a minimum commitment of 40 hours of service annually.



Assignment Preference

The following volunteer assignments may currently be available. Click the assignment names to learn more about the assignment. Use this list to select one assignment that interests you. Health Center needs, your time, availability and the interviewer's recommendation will be taken into consideration.



Background Check

Southwest Community Health System does conduct background checks on those age 18 years and older. A conviction does not necessarily disqualify an applicant. Failure to disclose may result in disqualification or termination.




Consent.

Please Read Carefully.


Health and Safety

I understand that, in participating in the Southwest Community Health System ("the Hospital") Volunteer Program, I/my child will be exposed to the normal risks of a hospital visitor or staff member.


I understand and agree that I waive for myself, my child and any heirs any and all claims including any negligence claims which I or my child might have against the hospital, or its agents or representatives, in any way arising from or relating to the Volunteer Program, except for claims arising out of the gross negligence or reckless or willful misconduct of the Hospital or its agents, or representatives. I hereby agree that I will not sue the Hospital on behalf of myself or my child, nor will my child sue on his/her own behalf, and release the Hospital from any claims I/my child, may have against it except for gross negligence or willful or reckless misconduct on the part of the Hospital, its trustees, officers, agents and employees.


In the event of exposure to blood or other bodily fluids from a patient who is a carrier of a contagious or infectious disease or a patient who is, in the judgment of the Hospital, at risk of carrying a contagious or infections disease, the Hospital shall, with my consent, administer immediate precautionary treatment to me/my child that is consistent with current medical practice without any further consent from me.


Background Check

I authorize the Hospital to use all legal means at its disposal to assess my suitability for volunteerism including obtaining a consumer report (criminal background record check) about me from a consumer reporting agency and consider such reports when making decisions about my volunteer application. I understand and agree that the Hospital or any agent acting upon their behalf, as well as any other person responding to a reference request pursuant to this application, can and will seek and/or disclose any and all information about me which said corporation, agent, or person may have. I specifically authorize said disclosure and agree to hold such corporations, agents, or persons harmless for same. That is, I will not file a lawsuit, claim or charge against them for such disclosure. Nor will I threaten same or otherwise seek any kind of compensation for such disclosure. I further release the Hospital, its officers, partners, affiliate agents and assigns from all liability or damages caused by inquiries regarding statements made in any consumer report accessed by the Hospital. I also understand and agree that the criminal background check may include a finger printing requirement.


Submission of Application

By submitting this form, I certify that all information I have supplied in this volunteer application and any other form, oral or written, is true and accurate, and I agree that any misstated, misleading, incomplete, or false information is grounds for rejection of this application form, refusal to be accepted as a volunteer or immediate discharge from the volunteer program without recourse, whenever and however discovered.


I understand and agree that submitting this application form does not automatically register me as a 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 signing this form, I agree that I have read, understand, and agree to the terms of this consent form, or in the alternative, that I have read this form to my child and he/she understands and agrees to its terms. I give my full consent to my/my child's participation in the Volunteer Program.






Volunteer Pledge

I understand and agree that submitting this application form does not automatically register me as a Southwest Community Health System 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.