Volunteer Engagement Application

Please complete this application form if you are interested in becoming a Blue Ridge Regional Hospital volunteer. Once you complete the form, click the Continue button at the bottom.

Contact Information

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Date of birth:

Availability

My availability is:

From:

to:

I would like to serve up to:

Emergency Contact Information

Have you ever been employed by/volunteered with Mission Health System? If yes, list position and dates.

First name:

Last name:

Home phone:

* OK to call here

Relationship:

Work & Volunteer Experience

Please list previous jobs and volunteer roles. Indicate if each role was as a paid employee or a volunteer.

Work History

Have you ever been dismissed or forced to resign from any job or volunteer position? If yes, please explain.

Current Enrollment Status

Are you currently enrolled at a college or university? If yes, list school and course of study.

Skills

Your check in the boxes below helps us learn more about your background. Please check as many as apply.

Preferences

Please check all that apply.

Assignment Preference:

Chaplain [Volunteer Services]

Coffee/Gift Shop [Volunteer Services]

Med/Surg [Volunteer Services]

Other [Volunteer Services]

Pet Therapy Handler [Volunteer Services]

Pet Therapy Leashless [Volunteer Services]

Registration / Greeter [Volunteer Services]

Special Project [Volunteer Services]

Surgery Waiting Room [Volunteer Services]

Why Do You Want to be a Volunteer?

How Did You Hear of Us?

References

Please use references who have known you at least one (1) year. Do NOT list physicians, relatives or anyone living with you. Provide complete mailing address, email addresses are preferred.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Email address:

Relationship:

3

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Email address:

Relationship:

Vaccination Requirements

All Mission Team Members, including volunteers, must comply with Mission Health's vaccination policies. A vaccination screening appointment with Mission WorkWell will be scheduled as part of the intake process. Please be ready to produce any available immunization records.

Current policy requires:
1. Varicella (chicken pox)Vaccine or proof of immunity
2. Tetanus, Diphtheria & Pertussis (tdap)vaccine
3. Measles, Mumps & Rubella (MMR) vaccine or proof of immunity (those born before January 1, 1957 are exempt from MMR vaccine)
4. Influenza vaccine for the current flu season
5. Tuberculosis screening

Volunteer Agreement

I hereby certify that the answers on this application and any resultant interviews are true and correct, and that any misrepresentation or omission of facts, misleading or false information on my part will be grounds for dismissal as a volunteer.

Acceptance as a volunteer is contingent upon satisfactory references, verification of the information submitted on this application, compliance with vaccination requirements and a criminal record check. I, therefore, authorize you make such investigations and inquiries you deem necessary in arriving at a decision.

I acknowledge and agree that I am not obligated, if called upon, to perform the volunteer services herein applied for, and Blue Ridge Regional Hospital Hospital Volunteer Engagement is not obligated to assign or actively seek to assign volunteer services for me.

I authorize that all employers, schools, or references thus contacted be released from all liability in answering questions related to my application.

I Agree