Volunteer Application Form

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

Name and address

First name:

Last name:

Street 1:

City:

State:

* Zip: *

Home phone:

OK to call me here

Cell phone:

Email address:

College:

Please list two (2) personal, educational or job references whom we may contact.

Demographic Information

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.

Birthday:

High school:

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

How did you hear about us?

Availability

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

Previous Employment

1

2

Employer name:

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

References

Please give us two (2) references. Contacts may not be family members.

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

OK to call here

Home phone:

OK to call here

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

Email address:

Relationship:

Emergency Contact

First name:

Last name:

Street 1:

City:

State:

Home phone:

Relationship:

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.

Volunteer Agreement

In submitting and signing 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 forty (40) hours of service per calendar year. If I am a college or high school 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 Vidant Bertie 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 Bertie 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 Bertie Hospital, to abide by my commitment, to keep all patient information strictly confidential, and comply with all rules and regulations. The statements given on this 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