Salem Health Student Volunteer Application

Thank you for your interest in becoming a student volunteer with Salem Health in Salem, Oregon. Student volunteers must be at least 14 years old.

NOTE: Students MUST attend an information session before applying. Please visit our website for details about the next info session and how to register.

http://www.salemhealth.org/volunteers/stu.php

Once you complete this application, click the "Continue" button at the bottom to submit your application.

( * indicates a required response; if not applicable, please enter "n/a".)

Name and Contact Information

Provide your name and contact information.

First name:

Last name:

Middle name:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

* OK to call me here

Cell phone:

OK to call me here

Email address:

Emergency Contact Information

Provide the name and contact information of the person you would want the hospital to contact in case of an emergency situation.

1

2

First name:

Last name:

City:

State:

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:

OK to call here

Cell phone:

OK to call here

Relationship:

Demographic Information

Your answers to these questions help us gather information about our volunteers.

Please list any languages OTHER THAN English that you speak in the fields marked Language 1 and 2.

Date of birth:

Pronouns:

Education:

Ethnicity:

Currently enrolled in school?:

School:

Languages Spoken (Other Than English):

Language 2:

Date Applied:

Availability

Student volunteers serve for a consecutive 6-month period. Each student serves one day a week, Monday through Friday, for 3 hours per shift.

Please indicate the days and times you are available weekly to volunteer. Students rarely volunteer on weekends or in the evening.

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

Talents, Skills and Interest

Use the checkboxes below to select the talents, skills and interest you have.

Employment History

List your current or past paid work experience experience. Feel free to include volunteer experience. Please answer "n/a" if you have not volunteered before or had a job.

1

2

Company:

First name:

Last name:

Street 1:

City:

State:

Zip:

Work phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Cell phone:

OK to call here

Email address:

Referral Information

How did you hear about the student volunteer program at Salem Hospital?

Source:

Referred By:

Please explain how you learned about volunteer opportunites with Salem Health. This information provides insight for program recruitment.

Application Question 1

Your responses to this question and the following questions assist us in determining if you are a good match for our program and help us in finding an appropriate placement for you as a volunteer candidate.

Please use your own words; do not copy and paste your answers from the hospital's website.

What is confidentiality? Why it is important for you to keep patient information confidential at all times?

Application Question 2

What is the best way to prevent the spread of germs at the hospital? What steps must you follow to avoid spreading germs when volunteering?

Application Question 3

What are the hospital's values? How could you use these values while volunteering at the hospital?

Application Question 4

In your own words, what is the mission of Salem Health?

Application Question 5

What are your goals for your volunteer experience? What do you want to get out of volunteering at Salem Hospital?

Student Volunteer Agreement

I certify that the information provided in this volunteer application is true, correct, and complete to the best of my knowledge. I understand that continuation of any subsequent volunteer placement depends upon true and accurate representation of the facts stated or implied herein. Additionally, I authorize Salem Health to make inquiries regarding my education, work experience, and references, unless otherwise stated. I hereby release all parties and persons associated with any such inquiries from all claims, liabilities, and damages for whatever reason in connection with information they give.

I acknowledge and agree that I am not obliged if called upon to perform the volunteer services herein applied for, and that Salem Health is not obligated to assign or actively seek to assign me to a placement.

I understand this application is not a contract of employment. If I am accepted as a volunteer, I agree to abide by and conform to all policies and procedures of Salem Health and Volunteer Services. I understand that my services are donated to the hospital without contemplation of compensation or future employment, and are given for humanitarian reasons. I understand that volunteering at the hospital does not mean I will get a paid position there in the future.

I have printed the Student Volunteer Form Packet from Salem Hospital's website, as I understand these forms must be completed and brought to my volunteer interview.

I Agree

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