Decatur Memorial Hospital Volunteer Application

Please complete this application if you are interested in becoming a Decatur Memorial Hospital volunteer. Once you complete the form, click the submit button at the bottom. Volunteers must be at least 16 years of age.

Onboarding Requirements

Following this application, new volunteers will be required to submit two letters of recommendation, complete a phone interview, onboarding packet, three in-person training sessions, criminal background check, a health questionnaire, TB & alcohol/drug testing, and will receive a flu shot, if during flu season. Volunteers who have not fulfilled these requirements cannot become an Active status volunteer.

Personal Information

Preferred first name:

Last name:

Middle name:

Title:

Legal first name:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Primary phone:

Secondary phone:

Email address:

Date of birth:

Over 16 Years of Age:

Why would you like to become a volunteer for Decatur Memorial Hospital?

Demographic

You may optionally provide demographic information. Demographic information is used only to help us have a better understanding of the make-up of our volunteer team.

Gender:

Ethnicity:

Marital status:

How did you hear about our program?:

Military Branch, if applicable:

Please use this space to provide any additional information that may be needed, including if you have ever served in the armed forces.

Volunteer Experience

Please describe your past volunteer experience.

Education

Current School, if student:

Current Year, if student:

Describe the highest level of education completed, and any special skills, training, professional licenses and/or certifications you may hold.

Employment

Are you currently employed?:

Employer name:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Work phone:

OK to call here

Please use this space to provide any additional information that may be needed.

Emergency Contact

Please list the person to be contacted in the event of an accident or illness.

First name:

Last name:

Nickname:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Primary phone:

Secondary phone:

Relationship:

Interests and Availability

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

Assignment Preferences

Please indicated the top areas you are interested in serving. More information about each assignment can be found by clicking on the assignment name. Your selection helps us in matching you to a fulfilling volunteer role and does not guarantee availability in one of these areas. The openings listed in the descriptions are subject to change.

Retired and Senior Volunteer Program (RSVP)

If you are part of the Retired and Senior Volunteer Program through Senior Corp, please complete this section. We will automatically send your hours and mileage for volunteering at DMH to RSVP. RSVP is a separate program from Memorial. To learn more, please contact RSVP at (217)528-4035.

RSVP/ Wants Mileage Reimbursement:

RSVP/ Round Trip Mileage:

RSVP Volunteer:

PLEASE REVIEW PRIOR TO PROVIDING AGREEMENT BELOW

I hereby affirm that the information on this application is true and complete. I understand that any false or misleading representations or omissions made on the application or during the orientation process may disqualify me from further consideration for a volunteer position and may result in discharge even if discovered at a later date.

I understand that Memorial Health System is not obligated to provide placement, nor are you obligated to accept a position, if one is offered. As a volunteer, I understand that my services are rendered on a gratuitous basis.

If completing this application as a hard copy, please sign the application as well.

I Agree

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