Please complete this application form if you are interested in becoming a Mariners Hospital Volunteer. Once you complete the form, check off I Agree, and click the Continue button.

Applicant Personal Information

First name:

Last name:

Middle name:

Title:

Address 1:

Address 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Other phone:

Email address:

Date of birth:

Age:

Gender:

School:

Skills:

Years in Monroe County?

Emergency Contacts

First name:

Last name:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Other phone:

OK to call here

Email address:

Relationship:

List Community Affiliations & Other Volunteer Work

Please list all your community affiliations and other volunteer work you were involve in the past.

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'd like to serve up to:

hours:

References

First name:

Last name:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Other phone:

OK to call here

Email address:

Relationship:

Worked at MH

Have you ever worked for Mariners Hospital,or any other entity of Baptist Health?. If yes, when and where?

Volunteered at BHSF

Have you ever volunteered for any BH Organizations?. If yes, when and where?

Family Affiliation at MH

Does anyone in your family currently work at Mariners Hospital?. If yes, who?

Any Convictions

Have you ever been convicted or found guilty (including nolo contendere) for a felony offense?

(Conviction of a crime will not necessarily deny volunteering. A criminal background check is part of the volunteer application process.)

If “YES,” please explain all convictions.

* Any Conviction?:

Yes

Volunteer Conditions

I understand that a volunteer at Mariners Hospital is minimally required to work four (4) hours per week, and a maximum of sixteen (16) hours per week. Exceptions will be based on job assignments and determined by the Director or Manager of Volunteer Services.
I understand that I must complete a tuberculosis evaluation annually, which may include a skin test.
I understand that I must complete a Flu shot yearly during Flu season (10/01 to 03/31).
I understand that I may be asked to volunteer days and/or hours other than those specified at the time of placement.
I agree to abide by all the rules, and policies of the Volunteer Services Department/Baptist Health South Florida. I will attend orientation, complete health office requirements, and complete all necessary training. I will observe the Volunteer dress code, and the code of ethics, and uphold the Service Excellence Standards. I will keep all patient information confidential as required by HIPAA and Baptist Health policies.
I certify that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts on this application will be sufficient cause for disqualification of this application.
I give permission for Mariners Hospital to verify any information provided in this application and I authorize my past references or any other persons to answer all questions concerning my ability, character, reputation, and previous employment or volunteer record. I release all such persons from any liability or damages resulting from having furnished such information.

I Agree