Please complete this application form if you are interested in serving on the Patient Family Advisory Council at Good Samaritan Medical Center as a volunteer. Once you complete the form, click the submit button at the bottom.


Name and Address


Contact Information


Emergency Contact

In the event of an emergency whom should we notify?



Education

Please indicate your highest level of education and provide the name of the school in which you are attending or have attended. Type the year you graduated or anticipate to graduate in the box.



Volunteer Experience

Please list all previous volunteer experience. Include name of organization, length of services and a description of the duties performed.



Interest

Why are you interested in serving on the Patient Family Advisory Council at Good Samaritan Medical Center?



Work Experience

Please list your current or most recent employer and include a description of responsibilities.



Court Record Information

Have you ever been charged and/or convicted of a crime? If yes, please explain and include date(s), location, and nature of crime.



Demographic Information


I Agree and Understand

I certify that the above information is true and complete to the best of my knowledge. I realize this information is confidential and may be used to determine my eligibility to serve in patient areas. I understand that I will be required to complete a background check and a health screening including: drug/alcohol testing, TB screening and will be asked to provide immunization records.


I agree to provide my services as a volunteer in a voluntary capacity without any employment-type benefits, including but not limited to employment insurance programs, worker's compensation accrual or benefits in any form, and this includes vacation or sick time.


I have been advised there is an inherent risk of contracting a contagious illness when working in a healthcare facility. I certify that I am responsible for discussing my volunteer service at the hospital and all recommended vaccinations with my personal physician/health care provider. The hospital does provide the influenza vaccine annually, but it is my responsibility to obtain any other vaccinations at my own cost.


I understand that Good Samaritan Medical Center is a drug-free work place and has implemented policies, including reasonable suspicion protocol that could affect volunteers. Violation of these policies could result in termination as a volunteer.


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