Doctors Hospital Adult Volunteer Application Form

In conjunction with applicable employment laws, this company does not discriminate because of age, sex, race, color, religion, marital status, national origin, veteran status or disability.

Please complete this application form if you are 18 and older and not currently enrolled in an academic institution. Once you complete the form, check off I Agree, and click the Submit button.

Applicant Personal Information

First name:

Last name:

Middle name:

Title:

Address 1:

Address 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Other phone:

Email address:

Date of birth:

Age:

Gender:

Skills:

Level of Education and Major Degree

Emergency Contacts

First name:

Last name:

Home phone:

OK to call here

Work phone:

OK to call here

Cell phone:

OK to call here

Other phone:

OK to call here

Email address:

Relationship:

Volunteer Experience

Please list your most recent volunteer experience including the name of the organization and the total hours served.

Availability

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

Sun

Mon

Tue

Wed

Thu

Fri

Sat

From:

To:

My availability is:

From:

to:

I'd like to serve up to:

hours:

Worked at BHSF

Have you ever worked for BHSF? If yes, when and where?

Volunteered at BHSF

Have you ever volunteered for BHSF? If yes, when and where?

Family Affiliation at DH

Does anyone in your family currently work at Doctors Hospital? If yes, who?

Any Convictions

Have you ever been convicted or found guilty (including nolo contendere) for a felony offense? Conviction

of a crime will not necessarily deny volunteering. A criminal background check is part of the volunteer

application process.

If “YES,” please explain all convictions.

If “NO”, please type “NO” inside the box below.

Volunteer Conditions

1- I certify that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation or

omission of facts on this application will be sufficient cause for disqualification for consideration, or if accepted separation from the program.

2- I give permission for Doctors Hospital to verify any information provided in this application and I authorize my past references or any other persons to answer all questions concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages resulting from having furnished such information.

3- I understand that I must complete all Occupational Health Office requirements including a tuberculosis evaluation, which may include a skin test.

4- I understand that a volunteer at Doctors Hospital is minimally required to work one four (4) hour shift and a maximum sixteen (16) per week. Exceptions will be based on job assignments and determined by the Manager of Volunteer Services. Exceptions will be based on job assignments and determined by the Manager of Volunteer Services. The minimum hours to be completed is 200 hours to receive a certificate and/or a verbal or written confirmation.

5- I must complete all orientation and training prior to volunteering. I understand that the orientation materials on the website are to be reviewed by me to prepare for the program orientation.

6- I agree to abide by all the rules and policies of Baptist Health South Florida, Doctors Hospital and the Doctors Hospital Volunteer Services Department.

7- I will comply with the drug free workplace policy.

8- I agree to abide by the Baptist Health code of ethics and keep all patient information confidential.

I Agree

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