UH Portage Medical Center Volunteer Application

Dear Future Volunteer,

Thank you for your interest in volunteering at UH Portage Medical Center. Our volunteers provide valuable service to patients, visitors and staff while enjoying a unique opportunity for personal growth and satisfaction.

Please complete this application form if you are interested in becoming a volunteer. Once you complete the form, click the submit button at the bottom of the screen.

After verifying your references, we will contact you to arrange an interview. For your interview, we ask that you bring these items:

1.Social Security # (Do not need card, just know #)

2.Volunteer Health Policy Statement and Immunization Information(this can be printed out from our website's volunteer page)

We look forward to meeting with you and pursuing your interest in volunteering at UH Portage Medical Center.

Sincerely,

UH Portage Medical Center Volunteer Services Department

(330) 297-2591

I Am Interested In:

* Volunteer Interest:

For Internship/Externship requests, you must include requested dates, hours requirement and department preference.

Volunteer Category

Adult Volunteer:18 years and older

Teen Volunteer: Age 14 - 17

Dog Category is for Wags For Wellness dogs only.

Type:

Contact Information

Please submit your name, address, phone number and email so that we may contact you.

First name:

Last name:

Middle name:

Title:

Nickname:

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

Email address:

Background Information

Information is used only to help us get a better idea of the demographic make-up of our volunteers; completion of certain sections is optional.

Date of birth:

Age:

Gender:

Ethnicity:

Emergency Contact

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

References

ADULT Volunteers:

Please provide 2 adult references we can contact, NOT RELATED TO YOU, who have known you for a minimum of 1 year. (examples include supervisors, teachers, coaches, ministers, work references, or adult friends).

TEEN Volunteer (age 14 - 17 yrs):

Print out and complete the School Recommendation/Parental Consent Form on our website's volunteer page.

References are contacted by phone so please provide best phone number/s to make contact with your references.

1

2

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Personal History

Have you ever been convicted of a felony or misdemeanor?

* Criminal History:

Yes

If yes, state offense, location and disposition. (Note: A conviction will not necessarily rule you out from volunteering)

Education

Education:

High School or College:

If you attended a school/university not listed, please include here:

Work Experience

Please list current or last employer, if applicable

* Employment Status:

Currently Employed

Not Currently Employed

Retired

Employer name:

City:

State:

Work phone:

If you ever worked or volunteered previously at UH Portage Medical Center or Robinson Memorial Hospital, please list dates of service and department.

Availability

Please indicate the days and times you would be available to volunteer.

Skills and Experience

Please check any special skills or interests that you feel could be incorporated into volunteer service.

Volunteer Experience

Please list your current or most recent volunteer experience, if applicable.

Briefly describe your most recent volunteer experience and your responsibilities there.

Please Read Carefully

Please read carefully & acknowledge below:

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, disability or veteran status.

I understand that I will be expected to abide by all volunteer policies. I also understand that I am committed to serve a minimum of 50 hours within 1 year for a traditional volunteer position or minimum two visits per month for Wags For Wellness.

I understand the application, interview, background check, and placement process are required of all volunteer applicants and are in no way a contract of volunteer service or promise of future volunteer service. I understand I will be required to attend the volunteer orientation and complete a two-step TB screening (free of charge at the hospital).

I certify that the above information I have given on this application is true and complete. I authorize investigation of all statements contained in this application and understand that my giving false information is sufficient for my discharge, if accepted. Due to the nature of some volunteer positions, I authorize the companies, schools or persons named in this application to provide information regarding me and hereby release them from liability for issuing this information.

I understand that I may be required to participate in a criminal records check prior to my volunteer service. This background check is conducted to ascertain whether I have been convicted of certain crimes or violations which could disqualify me from eligibility for volunteer service. If I fail to provide the information necessary to complete the required forms,I will no longer be considered for volunteer service. My volunteer service at UH Portage Med Center is contingent upon a records check that does not reveal any disqualifying offense(s). If I am accepted as a volunteer, my status will be conditional pending receipt of this information.

This organization is not obligated to provide a placement, nor am I obligated to accept the position offered.

I Agree