We appreciate your interest in the Volunteer Program at ECU Health Duplin Hospital. Please complete this application form so we can view your qualifications to serve our patients, their families and our staff. Questions on the application are asked for the sole purpose of considering you for volunteer service. We do not discriminate on the basis of race, religion, sex, national origin or handicap status. Once you complete the form, click the submit button at the bottom.

NAME AND ADDRESS

Please fill out the following requested information:

First name:

Last name:

Middle name:

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:

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

NAME AND ADDRESS

Social Security Number:______________________________

Demographics

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Why are you interested in becoming a volunteer at Vidant Duplin Hospital?

Skills & Experience

How did you hear about us?

Do you have any talents and/or skills that you would like to share?

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

I would like to serve up to:

hours:

Employment

1

2

Employer name:

First name:

Last name:

Street 1:

City:

State:

Zip:

Work phone:

Cell phone:

Email address:

Emergency Contact

First name:

Last name:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

References

Please enter two personal references, do not include family members.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Criminal History

Have you ever been convicted (pleaded guilty or been found guilty) of a misdemeanor or a felony? Please provide dates and details for any convictions and pending cases. Including but not limited to; major traffic violations, writing bad checks and DUI. *A conviction does not necessarily disqualify you from volunteering.

Have you ever plead guilty or been convicted of a crime other than a minor traffic violation? If so, explain.

Volunteer Agreement

In submitting and siging this application, I understand that my application will be reviewed by the Manager of Volunteer Services. if I am selected for an interview, I will be notified by phone or email. I also understand that compensation will not be granted for hours served, as this is strictly a volunteer position.

Commitment:

*I must provide a minimum of (40) hours of service per calendar year. If I am a college student I must provide to a minimum of at least one semester and thirty (30) hours of service.

*It is my responsibility to get the necessary transportation to and from volunteering.

*I understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties outside of my service guidelines.

Training/Health:

*A volunteer organization and health screening is required before volunteering at ECU Health Duplin Hospital.

*All current required immunizations will be given to me unless documented proof is submitted to Occupational health.

*I must undergo an update of the TB skin test and re-orientation annually.

*Management will follow up with me in a reasonable amount of time to ensure that the placement is satisfactory.

Acknowledgement of Hospital Criminal Record Checks

*Criminal record checks will be performed on every applicant volunteering at Vidant Duplin Hospital

*If the information that I have furnished on this form is found to be false, I could be disqualified/dismissed.

I hereby apply to become a Volunteer at Vidant Duplin Hospital, to abide by my commitment, to keep all patient information strictly confidential, and comply with all rules and regulations. The statements given on the application are true and accurate to the best of my knowledge.

Commitment:

I must provide a minimum of forty (40) hours of service per calendar year.

It is my responsibility to get transportation to and from volunteering.

I understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties outside my service guidelines.

I Agree