Please complete this application form if you are interested in becoming a UnityPoint Health - Finley Hospital volunteer. Once you complete the form, click the submit button at the bottom.

Contact Information

First name:

Last name:

Middle name:

Title:

Home Address:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

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:

Gender:

Education:

Race and Ethnicity:

Marital status:

Armed Forces:

Last 4 of social security:

High school:

College:

Skills & Experience

In which of these areas do you feel you have moderate to excellent skill and experience? Check all that apply.

Questions

Please answer these questions as thoroughly as possible.

How long of a commitment are you prepared to make? (We require a minimum of 60 hours total or 30 hours to be eligible to job shadow.)

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:

Assignment Preference

The following volunteer assignments may currently be available. You may click the assignment names to learn more that assignment. Use this list to rank your top three assignment choices.

Assignment Preference:

1st choice:

2nd choice:

3rd choice:

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Relationship:

Employer

Please list your current or most recent employer, if applicable.

Employer name:

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Work phone:

EMail

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

Email address:

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Work Reference

Professional references are people who can attest to your work ethic and include people you have worked for/with. For students this includes teachers, coaches, scout leaders, youth leaders, babysitting jobs.

Employer name:

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Primary phone:

Relationship:

Contacted:

Permission to Photograph (adults only)

I grant UnityPoint Health - Finley Hospital the right to take photographs of me in connection with volunteering at Finley Hospital. I authorize UnityPoint Health – Finley Hospital, its assigns and transferees, to copyright, use and publish the same in print and/or electronically.
I agree that UnityPoint Health - Finley Hospital may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. I have read and understand the above:

Permission to Photograph:

I Agree

By signing below, I certify that the answers and information said above are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete I may not be asked to participate in the volunteer program.

I authorize UnityPoint Health – Finley Hospital to investigate all statements contained in this application for employment to include criminal, child and dependent adult abuse information in accordance with Iowa and/or Illinois law, as well as my character and qualifications. I release Finley Hospital from all liability for actions performed in good faith and without malice in connection with evaluation of my application. I authorize my prior employers, references, and others with information regarding my work, educational history or my character, to provide UnityPoint Health - Finley Hospital with all information requested and to cooperate fully with the investigation of my character and qualifications. I agree to cooperate in such an investigation, and release from all liability and/or responsibility all persons, companies, or corporations supplying such information.

I certify that throughout the selection process, including the interview, I will provide information that is true, correct and complete to the best of my knowledge. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would unfavorably affect my application for a volunteer assignment.

I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant for a volunteer position at UnityPoint Health - Finley Hospital or my termination as a volunteer.

I also understand that this is an application for and not a commitment or promise of volunteer opportunity.

I understand that if I am offered a volunteer assignment, the offer is contingent upon receipt of satisfactory references and criminal/abuse/compliance background information, a physical health assessment, immunization documentation and TB testing.

I agree that at no time will any information regarding patients or operations of the hospital be revealed to anyone other than those authorized to receive it.

I understand, as a volunteer, I must conform to all the UnityPoint Health - Finley Hospital rules and regulations.

I voluntarily offer my services with a clear understanding that there is no monetary compensation.

UnityPoint Health - Finley Hospital seeks to provide a healthy, comfortable, and productive work and health care environment. In the event I am a volunteer of UnityPoint Health – Finley Hospital, I acknowledge and agree to abide by the UnityPoint Health - Finley Hospital "Tobacco-Free Environment" policy that smoking or any tobacco use is strictly prohibited anywhere on the UnityPoint Health – Finley Hospital campus.

UnityPoint Health - Finley Hospital is committed to providing equal opportunity in all areas of volunteering regardless of an individual's race, religion, age, sex, qualified disability or national origin except where these categories are a bona fide occupation qualification.

I Agree