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


Contact Information

Please list your full legal name. If you go by a nickname or a name other than your first name, please list it in the preferred name section.



Demographic Information

This information is used only to help us get a better idea of the demographic make-up of our volunteers. Please list the graduation year or anticipated graduation year if applicable.



Availability

Please Indicate the days and times you are usually available to volunteer and which assignment site you prefer. Note: Volunteer assignments are for 3-4 hours once a week, with a commitment of at least 6 months. Some sites are dependent on space and availability.



Employer and Volunteer Experience

Please list your current or most recent employer. If you are a USA Student Worker, please indicate this on the Job Title line. If you have not been employed, please list any volunteer experience.



Volunteer Session

University Hospital: Applications are accepted on an on-going basis. There are no specific session dates for orientation. If you have selected University Hospital as your first choice, please select University Hospital in the session drop down menu and a volunteer coordinator will reach out to for orientation dates.


Children’s and Women’s Hospital session dates are listed below. Please indicate which CW session you are applying for: Each session indicates application deadline and orientation dates/times.


Session 2:

Application deadline: January 24, 2020

Orientation dates: January 28 or January 30, 4-6p

Session dates: March 2-August 30, 2020


Session 3A:

Application date: April 26, 2020

Orientation date: May 5 or May 7, 4-6p

Session Dates: June 1-November 39, 2020


Session 3B:

This session designated for college students who are home for the summer. This does not apply to students who attend school locally. Volunteer are excepted to commit to 8 hrs a week


Application date: April 24, 2020

Orientation dates: May 5 or May 7, 4-6p

Session dates: June 1-August 8, 2020



Emergency Contact

In the event of an emergency, whom should we notify?



Professional References

Please list 2 professional references (e.g., teacher, employer, etc.). Please do not list personal references such as friends or family members.



Relatives Employed at USA

If you have any relatives who are employed through the University of South Alabama, please list their name and the department in which they work.



Health Information

All volunteers must email proof of the following to usahealthvolunteers@health.southalabama.edu PRIOR to submitting application.


1. Immunizations against MMR (measles, mumps, rubella)Two doses required.(If born before 1957 no documentation of MMR is required. If born after 1957, a self-reported 1st MMR is acceptable with a documented 2nd MMR booster).


2. Varicella vaccine (chicken pox) *TWO doses required or history of chicken pox.


3. Tuberculosis skin test: Volunteer applicants must provide written documentation of a negative test within the previous 12 months. Acceptable TB screening methods: interferon-gamma release assay (ICRA)(e.g., T-Spot, Quantiferon [QFT]), tuberculin skin test (TST).


Applicants without documentation of a negative test result during the preceding 12 months, will need to provide documentation of a 2-step Tuberculin Skin Test (TST):

1. initial TST (read at 48-72 hours), if negative;

2. a second TST (read at 48-72 hours) to confirm the first reading given 1-3 weeks from the first test


Applicants with history of Positive TB Screening Test requires documentation confirming a previous positive tuberculin skin test and documentation of a normal chest x-ray after a positive TB skin test.


4. One-time adult dose of Tdap vaccine.


5. A flu shot is mandatory (if you volunteer between September and April). The hospital offers free flu shots during session 1 or you may obtain shot through your healthcare provider.


Please list any medications, food, chemicals or products to which you are allergic. Also list any chronic medical conditions you may have (e.g., high blood pressure, diabetes, etc.) as well as medications you are currently taking.



Criminal History

Have you ever been convicted of a felony or misdemeanor (including pleading guilty and nolo contendere)? Falsification of this or any other information on the application is grounds for immediate dismissal. All volunteer applicants must agree to undergo a background screening paid for by USA Health's University Hospital.



About You: Question 1

Why do you want to volunteer at USA Health?



About You: Question 2

How did you learn about the volunteer program at USA Health?



I Agree

ACKNOWLEDGEMENT & CONFIDENTIALITY PLEDGE

The information I provided for this application is accurate and correct to the best of my knowledge. I approve USA Health to check references. USA Health is not obligated to provide a volunteer placement, nor am I obligated to accept the placement offered. Opportunities for volunteering are provided without regard to religion, creed, race, national origin, age or gender.


I recognize the necessity of maintaining the confidentiality of all data and documents collected and processed by USA Health. Confidential information is defined as proprietary business data or information which contains identifying information which can be linked to a specific individual or patient. I also recognize the importance of my part in assuring the right to privacy of persons and institutions cooperating with this facility. I further understand that this facility has both ethical and legal responsibilities to safeguard confidential information. Therefore, I will not divulge any confidential information I may encounter while volunteering at USA Health. Further, I will not make any copies of or transport off the premises any confidential information. I am aware, that in some instances, civil and criminal penalties are possible if unauthorized disclosure of confidential research records and data occurs. I agree to accept any liability which may accrue to this facility for any breaches of confidentiality which occur through my direct action.


I WILL ABIDE BY THE POLICIES OF USA Health. I UNDERSTAND THAT IF I VIOLATE ANY OF THESE POLICIES, I MAY BE DISMISSED FROM THE VOLUNTEER PROGRAM. I HAVE CONSIDERED THE SERIOUSNESS OF THE COMMITMENT I AM MAKING AS A VOLUNTEER.


BACKGROUND & HEALTH SCREENING REQUIREMENTS

I understand that, prior to my being accepted as a volunteer, USA Health will perform, or request that a third party perform a background investigation to determine my suitability for volunteering. I understand that if USA Health decides to make me an offer to volunteer that such offer is conditioned on my satisfactory completion of background and health screening requirements, including receiving annual flu vaccine.


RELEASE FROM LIABILITY

I understand that I will be voluntarily participating in the Volunteer Program at USA Health. In consideration of the University of South Alabama permitting me to participate in this activity, I, in full recognition and appreciation of any and all risks, hazards, or dangers, if any, inherent in this activity, to which I may be exposed, do hereby agree to assume all of the risks and responsibilities surrounding participation in such activity.


I do for myself, my heirs and personal representatives, hereby defend, hold harmless and indemnify, release and forever discharge the University of South Alabama, its trustees, officers, agents, servants and employees from and against any and all claims, demands and actions or causes of action on account of or resulting from my participation in this activity and/or which may result from causes beyond the control of, and without the fault or negligence of the University of South Alabama, its trustees, officers, agents, servants and employees, during the period of participation as aforesaid.


I fully understand the risks involved in this activity and agree to assume those risks. I understand that the University of South Alabama, its trustees, officers, agents, servants and employees assume and accept no liability for wages of any kind, personal injury or loss of life or damage to personal property.


PLEDGE TO MISSION

I pledge to be dedicated to the mission of USA Health ("We help people lead longer, better lives") and to abide by the Hospital's and Volunteer Services' policies and procedures.


I am confirming that I have read the above information, and I agree to abide by this information and I am responsible for knowing it.