Mariners Hospital Adult Volunteer Application Form
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:
Choose
Dr.
Miss.
Mr.
Mrs.
Ms.
Sir
Address 1:
Address 2:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
F
FD
FL
Florida
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Home phone:
Work phone:
Cell phone:
Other phone:
Email address:
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Age:
Gender:
Choose
Female
Male
School:
Skills:
Clinical Background
Customer Services Background
Education Background
Finance/Business Background
IT Background
Other Background
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:
Choose
Aunt
Boyfriend
Brother
Brother-In-Law
Coach
Companion
Cousin
Co-worker
Dad
Daughter
Daughter-in-law
Domestic Partner
Family Friend
Father
Fiance
Fiancee
Friend
Friends
Girlfriend
God Mother
Godmother
Grandmother
Grandparents
Grandson
Guardian
Husband
Mother
Neighbor
Nephew
Niece
Niece-in-law
Parents
Partner
Relative
Roommate
Significant other
Sister
Sister-in-law
Son
Spouse
Stepfather
Step-father
Stepmother
Step-mother
Supervisor
Teacher
Uncle
Wife
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:
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
To:
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
6:00am
6:15am
6:30am
6:45am
7:00am
7:15am
7:30am
7:45am
8:00am
8:15am
8:30am
8:45am
9:00am
9:15am
9:30am
9:45am
10:00am
10:15am
10:30am
10:45am
11:00am
11:15am
11:30am
11:45am
12:00pm
12:15pm
12:30pm
12:45pm
1:00pm
1:15pm
1:30pm
1:45pm
2:00pm
2:15pm
2:30pm
2:45pm
3:00pm
3:15pm
3:30pm
3:45pm
4:00pm
4:15pm
4:30pm
4:45pm
5:00pm
5:15pm
5:30pm
5:45pm
6:00pm
6:15pm
6:30pm
6:45pm
7:00pm
7:15pm
7:30pm
7:45pm
8:00pm
8:15pm
8:30pm
8:45pm
9:00pm
9:15pm
9:30pm
9:45pm
10:00pm
10:15pm
10:30pm
10:45pm
11:00pm
My availability is:
Choose
Ongoing
Ongoing, except between these dates
Only between these dates
From:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
to:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
I'd like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
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:
Choose
Aunt
Boyfriend
Brother
Brother-In-Law
Coach
Companion
Cousin
Co-worker
Dad
Daughter
Daughter-in-law
Domestic Partner
Family Friend
Father
Fiance
Fiancee
Friend
Friends
Girlfriend
God Mother
Godmother
Grandmother
Grandparents
Grandson
Guardian
Husband
Mother
Neighbor
Nephew
Niece
Niece-in-law
Parents
Partner
Relative
Roommate
Significant other
Sister
Sister-in-law
Son
Spouse
Stepfather
Step-father
Stepmother
Step-mother
Supervisor
Teacher
Uncle
Wife
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.)
YES NO
If “YES,” please explain all convictions.
Volunteer Conditions
1. 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.
2. I understand that I must complete a tuberculosis evaluation annually, which may include a skin test.
3. I understand that I must complete a Flu shot yearly during Flu season (10/01 to 03/31).
4. I understand that I may be asked to volunteer days and/or hours other than those specified at the time of
placement.
5. 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.
6. 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 Baptist 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