Please complete this application form if you are interested in completing an unpaid internship at Augusta University Medical Center for academic credit. Once you complete the form, click the submit button at the bottom.


Name and 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 and interns.



Emergency Contact Information

Please list the name and contact information of someone we can contact in the event of an emergency.



Education

Please list the college or university that you attend, your projected graduation month and year, and the dates of the internship you are requesting.



Employment


Reference

Please include the name and contact information for one reference.



Availability

Please indicate the days and times you are usually available to intern each week.



Email Preferences

We like to keep interns 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.



Additional Information

Please list any other information that you would like to share with the Volunteer Services Department regarding your internship.



Volunteer Agreement

If accepted into the internship program, I agree to:


1. Hold as absolutely confidential all information that I may obtain directly or indirectly concerning patient and staff and not seek to obtain confidential information from a patient.


2. Become familiar with the organization’s policies and procedures and uphold its philosophy and standards.


3. Donate my services to the organization without contemplation of compensation or future employment.


4. Be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others and strive to make my work professional in quality.


5. Attend orientation and in-service training as scheduled.


6. Carry out assignments and seek the assistance when necessary.


7. Take any problems, criticism or suggestions to my area supervisor or to the Manager, Volunteer Services.


8. Work a specified number of hours on a schedule acceptable to the organization and me.


9. Adhere to the department’s sign-in policy.


10. Notify the Volunteer Services office and my assigned placement area if absence occurs.


11. Intern in assigned area for duration of internship required. Failure to so will result in an incomplete internship and school will be notified accordingly.


12. I understand that the Volunteer Service program reserves the right to terminate my internship status as a result of: (a) failure to comply with organizational policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance or (d) any other circumstances which, in the judgment of the department director, would make my continued service as a volunteer contrary to the best interests of the organization.


I have read each of the preceding statements and I agree to abide by them.