Complete this form to become an IU Health Volunteer for the East Central Region—Ball, Blackford, or Jay. When you reach the bottom of the page, check agree and submit. If you are under the age of 18 years, your parent or legal guardian will need to check the box, thus giving you permission to pursue volunteering at IU Health. Please refrain from using personal friends or family members as your personal reference.

Personal & Contact Information

Please complete.

First name:

Last name:

Middle name:

Nickname:

Street 1:

Street 2:

City:

State:

* Zip: *

Best Contact phone:

* OK to call me here

Other phone:

OK to call me here

Cell phone:

OK to call me here

Demographic Information

You may optionally provide the following information. It is used only for the purpose of understanding the demographic make-up of our volunteer population.

Date of birth:

Age:

Gender:

Education:

Marital Status:

Ethnicity:

RN/LPN:

Preferences

Tasks I believe I would like to do:

Availability & Schedule

Please tell us your availability including the number of hours you want to volunteer.

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Best Contact phone:

Relationship:

Employer and/or Volunteer Experience

Please provide either your employer name or volunteer agency name. Indicate the contact information for your supervisor.

Employer or Volunteer Agency:

First name:

Last name:

Best Contact phone:

Email address:

Please share your most and least positive employment or volunteer experiences.

EMail

Please include your preferred email address. If you opt out of email by unchecking any of the boxes, this will prevent you from getting important information about your volunteer requirements.

Email address:

What kinds of email would you like to receive?

Electronic newsletters
Quarterly publications to keep you abreast of the happenings in Volunteer Resources and at IU Health Ball

Recruitment appeals
Latest information on volunteer opportunities.

Checklist items
Checklist items due or complete

Checklist reminders
Checklist reminders assist us in helping you meet the on-going requirements of being a volunteer.

Type

Please indicate if you are a teen, college or adult volunteer candidate by checking the appropriate box.

Type:

I Agree

I understand and agree that submitting this application form does not automatically register me as an IU Health Ball Memorial Hospital volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures, as well as a health and background screen before I may begin volunteering.

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

If under the age of 18 years, a parent or legal guardian, acknowledges full responsibility for any volunteer joining the teen program.

I Agree