Please complete this application form if you are interested in becoming a University of Vermont Health Network-Champlain Valley Physicians Hospital volunteer. Once you complete the form, click the submit button at the bottom. Should you have any questions, please contact the Volunteer Office at (518)562-7595

Name and address

First name:

Last name:

Pronouns:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

OK to call me here

Work phone:

OK to call me here

Email address:

Emergency Contact Information

First name:

Last name:

Pronouns:

Home phone:

Work phone:

Cell phone:

Relationship:

Employment History

Please list one recent employer or leave blank if you have no employment history

1

2

Business:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

OK to call here

Work phone:

OK to call here

Email address:

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.

Date of birth:

Gender:

Education:

School:

Skills:

Ability to follow written instructions

Ability to handle stressful situations

Ability to multi-task

Ability to stand/walk for extended time

Excellent computer skills

Excellent interpersonal skills

Excellent phone skills

Familiarity with computer

Reliable and dependable

Assignment Preference:

1st choice:

2nd choice:

3rd choice:

Availability

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

Personal History

References:

Previously Convicted of a Crime:

If you answered "Yes" to previously convicted of a crime, please explain.

Volunteer History

Please list your previous volunteer experiences.

Personal Narrative

Please detail why you are interested in volunteering at UVM Health Network - CVPH.

Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.

Agreement

If I misrepresent or deliberately leave out a fact in my application, I may be refused volunteer status, or have my volunteer status revoked. UVM Health Network - CVPH has my authorization to thoroughly investigate my work, medical and personal history. I will hold no person liable for giving or receiving information in this investigation. Any physician, hospital, or testing laboratory may conduct medical tests to determine my ability to perform volunteer duties now or in the future, and may release all information necessary to UVM Health Network - CVPH. I understand that this is not an application for employment, and that granting of volunteer service will not confer an employment status. I agree to confine my activities at UVM Health Network - CVPH within the volunteer program. I may terminate my volunteer status at any time without cause and UVM Health Network - CVPH may terminate or modify the relationship at any time without cause. In consideration of volunteer status, I agree to conform to the rules and regulations of UVM Health Network - CVPH. I have read and agree to the above and certify that the facts I have provided in my volunteer application are true and complete.

I Agree