Please complete this application form if you are interested in becoming a volunteer at Penn State Health St. Joseph. Click the submit button at the bottom of the form once you have completed it.


Name and address


Demographic Informaton

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.



Educational background

If you are currently in school, please provide your current year of education, as well as your future educational goals.



Email

The vast majority of our communication will be by email.



Profile

If you are applying as a pet therapy volunteer, please include the name of your therapy dog(s).



Background Information

Please use the box below to answer theses questions:

Do you have physical restrictions that must be considered in your placement? If yes, please explain

Have you been convicted of a crime within the past five years?

Volunteers under age 18:

Special Health Problems, allergies, and medications

Name of Physician:

Physician Phone:



Reason for volunteering

Individuals volunteer for a variety of great reasons. Understanding your goal will help us match you with the best volunteer opportunity.



Applicant Authorization

APPLICANT’S STATEMENT

I authorize Penn State Health – St. Joseph to verify the information I have provided on this application. I understand that any misstatement, omission or misleading information given in my application or interview or in connection with other Penn State Health – St. Joseph’s records may result in the rejection of my application or my dismissal as a volunteer. I authorize Penn State Health – St. Joseph to make a thorough investigation and release from all liability all persons and entities, including my present employees, requesting or supplying information about my education, employment and activities, personal and otherwise.


All volunteer opportunities are contingent upon the review of references (when appropriate), background checks and other relevant information. Any misleading or incorrect statements, omissions or failure to disclose any healthcare related criminal conviction or any threatened or actual debarment, exclusion or other ineligibility of participation in federally funded health care programs may remove this application from further consideration.


Penn State Health – St. Joseph does not discriminate on the basis of an individual’s race, color, religion, sex, national origin, disability, veteran’s status or any other characteristic protected by federal, state or local law.