Please complete this application form if you are interested in becoming a UnityPoint Health - Des Moines at Iowa Lutheran Hospital Volunteer Services volunteer. Once you complete the form, click the submit button at the bottom.

Please note, all volunteers must go through a screening process prior to joining the team that includes:
- Orientation Handbook Review
- State of Iowa Background Check
- Federal Background Check (if applicable)
- Health Screening
- TB Testing
- Flu Vaccine (if applicable)
- Commit to 6 months

Name and Address

Please complete below.


Residency Outside of Iowa (last 7 years):

If you have lived outside of Iowa within the past 7 years, please select "Yes". Otherwise, select "No".


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.


Availability

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


Hobbies


Employment Experience

If employed, please list your employer. If retired, please list your previous work experience.


Why are you interested in volunteering?


Medical Information

Please list any medical conditions we should be aware of in case of emergency.


Background

Do you have a record of founded child or dependent adult abuse or have you been convicted of a crime in this state or any other? If so, please specify.


Emergency Contacts


Agree

I agree that the answers and information included are accurate and complete to the best of my knowledge. I acknowledge that any answer or information is not accurate or incomplete, I may not be asked to volunteer.

1. I authorize UnityPoint Health Des Moines to investigate all statements contained in this application for volunteer services, as well as my character and qualifications. I release UnityPoint Health-Des Moines from all liability for acts performed in good faith and without malice in connection with the investigation of my background and evaluation of my application.

2. I authorize my past and present employers, volunteer organizations, and others with information regarding my work, volunteering, or my character to provide UnityPoint Health-Des Moines with all the information requested and to cooperate fully with the inquiry of my character and qualifications. I also release those employers, references, and others from all liability for providing information in good faith without malice.

3. I understand and agree that the relationship between myself and UnityPoint Health-Des Moines may be terminated at any time by either party.

4. I understand that my acceptance to volunteer in patient contact areas depends on UnityPoint Health-Des Moines ensuring that I have no health problems which would prevent me from volunteering effectively and with complete safety for myself and UnityPoint Health-Des Moines' patients, employees, and visitors. Accordingly, I agree that I will submit to a health evaluation through UnityPoint Health-Des Moines health services department and that my acceptance to volunteer will depend upon approval by the health services department.

5. I understand that as a volunteer, I must conform to all of UnityPoint Health-Des Moines rules and regulations, including those in the orientation manual. I also understand that I will be required to obtain and wear the appropriate volunteer uniform. this uniform includes a name tag and a jacket or vest.

6. Please note that your volunteer commitment at UnityPoint Health-Des Moines includes a commitment to confidentiality. Names, diagnoses, and other patient/client information must not be shared. Discussing a patient/client or the patient's/client's condition in the halls, cafeteria, or any location which may provide others the opportunity to overhear is strictly prohibited and could create legal liability for UnityPoint Health-Des Moines and for you. This commitment to confidentiality extends to all communications taking place not only in the hospital but outside the hospital too.

7. I hereby give permission for UnityPoint Health-Des Moines to conduct an Iowa criminal history and dependent adult/child abuse registry check with the Division of Criminal Investigation.