Volunteer Application Form

Please complete this application if you are interested in becoming a Littleton Adventist Hospital volunteer. Once you complete the form, click the Submit button at the bottom of the form.

Volunteer Information

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip: *

Home phone:

* OK to call me here

Work phone:

OK to call me here

Cell phone:

* OK to call me here

Date of birth:

* (year optional)

Age:

Gender:

Why do you want to volunteer at Littleton Adventist Hospital?

EMail

Email address:

Areas of Interest

Check one or more areas of interest.

Skills & Experience

Check the skills below that you either enjoy or have experience in. Check all that apply.

Availability

Please indicate the days and times you are usually available to volunteer (4-hour shifts).

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

I Agree

I understand and agree that submitting this application form does not automatically register me as a Littleton Adventist Hospital volunteer, and that there will be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

A TB Test is required of all volunteers. If you have had a TB test within the current calendar year, you must provide verification at time of interview. If this document is not available, the hospital lab will do a FREE blood draw. If you are not immune, you may obtain a vaccination from your Primary Care Physician. Vaccination is not mandatory.

An annual Flu Shot is required of all volunteers, and no exceptions can be granted. Volunteers can receive a FREE flu shot at the hospital lab or provide verification from another medical facility.

A Background Screening Authorization is required before individuals are eligible to volunteer at Littleton Adventist Hospital. The information will be used for the sole purpose of identification.

By submitting this form, I indicate my commitment to volunteering on a weekly basis for a minimum of six (6) months. I do confirm that I will honor the confidentiality of all patients. At no time will I mention or discuss patients in the hospital or away from the hospital. I also confirm my understanding that I am not covered by the hospital's workman's compensation policy, and if I am injured, my personal health insurance will be solely responsible.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

I Agree