Adult Volunteer Application

Thank you for your interest in volunteering at Regina Hospital! A valid email address is required to complete this on-line application and will be used as a communication tool in the application process. Email addresses are kept confidential and are not shared. All items with an Asterick (*) are required fields. Once you complete the form, select the continue button at the bottom. Thank you!

Name and Address

First name:

Last name:

Middle name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

Date of birth:

Education

Please enter the highest level of education completed.

Education:

Major degree:

High school:

College:

Work/Personal Experience

Please note any relevant work experience in the comment box, either volunteering or paid.

Unemployed:

Retired:

Employer name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

OK to call here

Emergency Contact Information

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Relationship:

Personal References

Please provide a personal reference who is not a relative.

1

2

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

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

Relationship:

Assignment Preference

Please select general areas that are of interest to you keeping in mind that your choices may change as you learn more about us!

Assignment Preference:

Please provide one or two brief statements in the comment box as to why you want to volunteer at Regina Hospital.

Special Skills

Please list any skills you have that may assist us in placement or that you particularly want to share.

Availability

Volunteer shifts are once a week or two but can be more often depending on your availability. Shifts are offered according to department need. Typically, we ask volunteers to make a minimum commitment; this is determined by needs and shift preferences. Note additional comments about your availability you would like us to know in the box below.

My availability is:

From:

to:

# Hrs:

hours:

Days of Week:

Times

Assignment

Email Preferences

We like to keep volunteers informed of important news, schedules, 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*. Please provide your preferred email address to receive communication and information from Regina Hospital. Thank you.

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Immunization Information

Prospective volunteers must verify immunity to measles, mumps, rubella, chicken pox and tuberculosis. Sometimes, a blood test is required if you are not sure of your vaccinations. and this is provided at no cost to you if we require a test. Additionally, if vaccines are needed, they may also be offered to you at no cost. After receipt of this application, you will be contacted and forms will be sent to you.

Background Study Requirement

Allina Health, including subsidiaries and affiliate corporations, will be ordering a background report. For the purpose of the preparing the background study, we will send you a form to complete authorizing us to to do so. Please provide your driver license number here including the State that issued the license.

Please type in your DRIVER LICENSE NUMBER and the STATE that issued it here.

Volunteer Applicant Consent

Thank you for taking the time to complete this application. By checking this box, you are indicating that the information in this application is accurate and correct to the best of your knowledge and it allow us to share information with the Regina Auxiliary if you decide to apply for membership with their organization.

Failure to fully and truthfully complete this application may result in denial of volunteer service or termination from the service. Allina Health, Regina Hospital is not obligated to provide placement, nor are you obligated to accept the position offered. We reserve the right to place volunteers in the areas we feel is best suited to their needs and the needs of the hospital.

EEO/AA

Adult Volunteer Application

I Agree