Volunteer Application

1Your Information

2Reference Information

3Volunteer Agreement

Personal Data

Name*

First Middle Last

Date of Birth*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Secondary Phone

Do you speak any foreign languages?*

Yes

Please list the foreign languages you speak:

Have you ever been convicted of a crime?*

Note: Convictions include guilty plea and please of nolo contendere. A conviction will not necessarily bar you from volunteer status. Each conviction will be judged on its own merits as to time, circumstances, and seriousness.

Yes

Please explain:*

Emergency Information

Emergency Contact Name*

First Last

Relationship to You*

Home Phone Number*

Mobile Phone Number

References

Please list two personal references other than family.

Reference #1: Name*

First Last

Reference #1: Contact Number*

Reference #1: Relationship to You*

Reference #2: Name*

First Last

Reference #2: Contact Number*

Reference #2: Relationship to You*

Today's Date*

Signature*

I certify that this application is correct to the best of my knowledge and understand that references will be checked.

If accepted as a hospital Volunteer, I agree that:

I shall hold absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors, or personnel, and not seek to obtain confidential information from a patient.
My services are donated to the hospital without contemplation of compensation or future employment, and given with humanitarian, religious, or charitable reasons.
I understand that it is a crime to solicit business for attorneys. I shall not solicit any business for attorneys or insurance companies, both on or off hospital property or act as a runner or capper for an attorney in the solicitation of business. I shall report all known occurrences of solicitation for attorneys to the Manager of Community and Corporate Relations.
I shall not sell or attempt to sell goods or services, request contributions, or to solicit persons to sign or distribute political petitions on hospital premises unless I receive the express authorization of the Manager of Community and Corporate Relations to engage in these activities.
I shall be punctual and conscientious; conduct myself with dignity, courtesy, and consideration of others and endeavor to make my work professional in quality.
I shall attempt to resolve any problems related to my Volunteer activities with the Manager of Community and Corporate Relations.
I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept.
I shall, at all times, uphold the philosophy of the hospital.
I understand that the Manager of Community and Corporate Relations reserves the right to terminate my Volunteer status as a result of (a) failure to comply with hospital policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work, or appearance; or (d) any other circumstances, which in the judgement of the department manager, would make my continued service as a Volunteer contrary to the best interests of the hospital.

Signature*

I have read the above conditions and agree to be bound by them.

Memorial Hospital Auxiliary Online Volunteer Application

Personal Data

Emergency Information

Volunteer Experience

Questionnaire

Other

References

If accepted as a hospital Volunteer, I agree that: