______(Last Name) (First Name) (Middle Initial) (Date)

Volunteer Application

PERSONAL INFORMATION:

______(Last Name) (First Name) (Middle Initial) (Date)

______(Street Address) (Apt. #) (City) (State & Zip Code)

Phone Number: ______Cell: ______

Email:______Birthday: _____/_____/______(month/day/year)

(minimum age requirement is 16 yrs.)

Social Security Number: ______

WORK STATUS:____Employed ____Retired ____Unemployed ____Student (High School/College) ____Year?

Current occupation: ______

SKILLS/WORK EXPERIENCE:

____Accounting ____Leadership ____Computer ____Nursing ____Teaching ____Public Speaking

Do you speak/write/read another language fluently? _____ Language: ______

IN CASE OF EMERGENCY PLEASE NOTIFY:

Name: ______Relationship: ______

Address:______

Home Phone Number: ______Cell Phone:______

Physician:______Phone Number:______

How did you hear about our program? ____Friend ____Newspaper ____Brochure ____Other (please specify)______

Volunteer availability: (please indicate the days and times you are available to volunteer)

______

What is your reason for volunteering/previous volunteer experience/interests: ______

Type of volunteer work interested in: (please check any that would interest you)

____Working with patients/ families ____Greeter/Helper/Patient Escort ____Emergency Room

____Behind the scenes (administrative/clerical) ____Reception/Waiting Room ____ Menu Delivery

____Admitting/Information Desk

Have you ever committed, been convicted of, pled guilty to, or pled no contest to, a felony or a misdemeanor? NOTE: Conviction of a crime is not necessarily grounds for disqualification.

____NO ____YES – If Yes, please explain:______

References:

List two (2) personal references with phone numbers:

Name: ______Phone: ______

Name: ______Phone: ______

(I authorize the references listed above to provide San Dimas Community Hospital with information relevant to volunteering).

As a volunteer, I

·  Agree to complete the volunteer orientation,

·  Agree to complete an ANNUAL education review and TB screening as well as any additional service-specific training that may be deemed necessary,

·  Agree to comply with all the rules and regulations of San Dimas Community Hospital,

·  I agree to maintain my own uniform and dress accordingly to volunteer standards,

·  Understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties outside of my service guidelines and I am free to resign at any time,

·  Understand that San Dimas Community Hospital may discontinue the volunteer relationship where it believes it is in the hospital’s and/or patient’s best interest,

·  Agree to call my Department Contact as soon as possible when I have scheduling changes

CONFIDENTIALITY: Information regarding the names of individuals, and/or treatment they are undergoing must be treated in strict confidence and must not be communicated in any manner. Any person participating as a volunteer must adhere to the confidentiality statement of San Dimas Community Hospital. Any unauthorized viewing, discussion, or disclosure of an individual’s information could result in litigation and/or prosecution.

San Dimas Community Hospital and affiliates believe that all medical, financial and personal information is confidential and is protected from unauthorized viewing, discussion, and disclosure. Therefore, staff members, volunteers, and students may look at, use, or disclose patient’s information ONLY as it relates to the performance of their duties. Any unauthorized viewing, discussion or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential, it is your responsibility to discuss the matter with your supervisor or staff member authorizing your visit before any breach of confidentiality occurs.

By entering my name below, I confirm that the information provided in this application is true in all respects, without any willful omissions. I understand that if this application is false in any way I will be dismissed without notice regardless of when the false information is discovered.

______

(SIGNATURE) (DATE)

OFFICE USE ONLY

Date Application Received:_____/_____/_____ Interview Date:_____/_____/_____

Service Area Discussed:______

Preferred Days:______Shift:______

Orientation Date: _____/_____/_____ Completed: _____/_____/_____

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