Volunteer Application Form

Thank you for your interest in volunteering at Vidant Health. Once you complete the form, click the submit button at the bottom.

You will receive an email telling you the next steps in the process.

Personal Information

First name:

Last name:

Middle name:

Title:

Nickname:

Street 1:

Street 2:

Street 3:

City:

State:

Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Availability

Work & Volunteer Experience

Please list previous jobs and volunteer roles. Indicate if each role was as a paid employee or volunteer

Vidant Health Experience

Have you ever been employed by/volunteered at any Vidant Health location? If yes, please list Vidant location, position, and dates.

Work History

Have you ever been dismissed or forced to resign from any job or volunteer position? If yes, please explain.

Current Enrollment Status

Are you currently enrolled at a high school, college, or university? If yes, list school and course of study.

Skills

Please let us know your skills to help us learn more about you. Skills such as retail sales, clerical skills, computer skills, customer service and fluent in Spanish, French, etc. are what we are looking for.

Criminal History

Have you ever been convicted (pleaded guilty or been found guilty) of a misdemeanor or a felony? Provide dates and details for any or all convictions and pending cases below. Including but not limited to major traffic violations, writing bad checks and DUI.

* A conviction does not necessarily disqualify you from volunteering.

Have you ever pleaded guilty or been convicted of a crime other than a minor traffic violation? If yes, explain.

Preferences

Share your ideas about specific volunteer placement areas.

Why do you want to be a volunteer?

How did you hear of us?

References

1

2

First name:

Last name:

Street 1:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Please use references who have known you at least one (1) year. DO NOT list physicians, relatives or anyone living with you. Provide complete mailing address. Email addresses are preferred.

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 notified by phone. I understand that this position is not paid and strictly volunteer.

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 Chowan 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 Chowan 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 Chowan 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