Volunteer Application Form
Please complete this application form if you are interested in becoming a Vidant Health 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:
Choose
NC
*
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:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
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31
*
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.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
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
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10
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28
29
30
31
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
*
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
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13
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15
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17
18
19
20
21
22
23
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25
26
27
28
29
30
31
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
*
Assignment Preference:
ASU [Vidant Chowan Hospital\Volunteer Services]
Clergy [Vidant Chowan Hospital\Volunteer Services]
Dementia Comfort Companion [Vidant Chowan Hospital\Volunteer Services]
Emergency Department [Vidant Chowan Hospital\Volunteer Services]
Gift Shop [Vidant Chowan Hospital\Volunteer Services]
Human Resources [Vidant Chowan Hospital\Volunteer Services]
ICU [Vidant Chowan Hospital\Volunteer Services]
Information Desk [Vidant Chowan Hospital\Volunteer Services]
InPaitent Unit-ED [Vidant Bertie Hospital\Volunteer Services]
IT Services [Vidant Chowan Hospital\Volunteer Services]
IT [Vidant Bertie Hospital\Volunteer Services]
Lab [Vidant Chowan Hospital\Volunteer Services]
Marketing/Wellness [Vidant Chowan Hospital\Volunteer Services]
Med/Surg [Vidant Chowan Hospital\Volunteer Services]
No One Dies Alone [Vidant Chowan Hospital\Volunteer Services]
Nutrition Services [Vidant Chowan Hospital\Volunteer Services]
Outpatient Services Center [Vidant Chowan Hospital\Volunteer Services]
Patient Access [Vidant Chowan Hospital\Volunteer Services]
Patient Access Services [Vidant Bertie Hospital\Volunteer Services]
Pet Therapy [Vidant Chowan Hospital\Volunteer Services]
Pet Visitation [Vidant Bertie Hospital\Volunteer Services]
Pharmacy [Vidant Chowan Hospital\Volunteer Services]
Purchasing 1 [Vidant Chowan Hospital\Volunteer Services]
Quality Department [Vidant Chowan Hospital\Volunteer Services]
Radiology [Vidant Chowan Hospital\Volunteer Services]
Rehab [Vidant Chowan Hospital\Volunteer Services]
Rehab Admin [Vidant Chowan Hospital\Volunteer Services]
Respiratory [Vidant Chowan Hospital\Volunteer Services]
Special Event [Vidant Bertie Hospital\Volunteer Services]
Special Event [Vidant Chowan Hospital\Volunteer Services]
TB Fair [Vidant Bertie Hospital\Volunteer Services]
Teddy Bear Fair [Vidant Chowan Hospital\Volunteer Services]
VBER Rehab [Vidant Bertie Hospital\Volunteer Services]
Vidant Family Medicine - Windsor [Vidant Bertie Hospital\Volunteer Services]
Vidant Medical Group [Vidant Chowan Hospital\Volunteer Services]
Volunteer Services [Vidant Chowan Hospital\Volunteer Services]
*
Location:
Vidant Bertie Hospital
Vidant Chowan Hospital
Do you have any volunteer experience? If so, where?
Previous Employment
1
2
Employer name:
Employer name:
First name:
First name:
Last name:
Last name:
Street 1:
Street 1:
City:
City:
State:
Choose
NC
State:
Choose
NC
Zip:
Zip:
Home phone:
Home phone:
Work phone:
Work phone:
Cell phone:
Cell phone:
Email address:
Email address:
References
Please give us two (2) references. Contacts may not be family members.
1
2
First name:
*
First name:
*
Last name:
*
Last name:
*
Street 1:
*
Street 1:
*
City:
*
City:
*
State:
Choose
NC
*
State:
Choose
NC
*
Zip:
*
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:
Cell phone:
Email address:
Email address:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
Emergency Contact
First name:
*
Last name:
*
Street 1:
*
City:
*
State:
Choose
NC
*
Home phone:
Relationship:
Choose
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Son
Spouse
Supervisor
*
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
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