Adult Volunteer Profile

The applicant has two submission options. You may either submit the following application electronically or may send the application via regular mail to:

Stormont-Vail Regional HealthCare
1500 SW 10th Avenue,
Topeka, Kansas 66604-1353
*Required
Full Name (first, middle, last)*
Full name is required.
List other names under which your records may be found
Birthday
Address*
 Address is required.
City*
 Enter your city.
State*
 Enter your state.
Zip*
Enter your zip code.
Former Address
City
State
Zip
Home Phone*
 Enter your home phone.Invalid format. Input must appear as (###) ###-####
Work Phone
Place of employment
(if applicable)
Work Phone
Cell Phone (optional)
E-Mail Address*
Your email is required.Invalid format.
Best days and time
to contact you
Emergency Contact (must be completed)
Name of person to contact
in case of emergency
Relationship to you
Phone
Please list any relatives employed at Stormont-Vail:
Name
Relationship
Department

Indicate the reason you are seeking a volunteer position (check all that apply)

Personal fulfillment

Professional development

Family/friends volunteer

Extra time

Requirement for class/degree

Other

Are there any groups with whom you would not feel comfortable working?
 Yes No
If yes, who are they?
How long a commitment
can you make?*
 Please make a selection.If other, please specify:

How did you learn about Stormont-Vail?

friend

instructor

clergy

television

poster/flyer

radio
employer co-worker Other
newspaper newsletter

Briefly state what you see as the benefits of volunteer service:

Briefly state what you see as the disadvantages of volunteer service:

List your previous work experience:

List your previous volunteer experience:
List any extra curricular activities which may help in considering your application

Please explain any conditions which may affect your ability to work with others:

Court Referral
Have you been convicted of a misdemeanor or have charges pending?
 Yes No
Have you been convicted of felony
 Yes No
If yes, when?
where?
Have you been ordered by a judge to do community service as an alternative to a fine or jail sentence?
 Yes No
If yes, how many hours and
in what amount of time?
Name of Probation Officer
Phone Number

Reference (Two references must be completed and one reference must be a professional
or business contact. Please exclude relatives.)
Name
Address
Phone
Relationship

Name
Address
Phone
Relationship

Is there a particular type of volunteer work in which you are interested (check all that apply)

one-on-one work

no preference

administrative/clerical duties

short term

public speaking/fund raising

long term
working with several people other
leadership position

Skills and Interests

Art

Typing
Crafts Journalism
Computer Other
Clerical

Placement Information

Days

Times
Sunday Mornings
Monday Afternoons
Tuesday Evenings
Wednesday Weekends
Thursday Other
Friday Days unavailable
Saturday

Please read the following carefully and sign below
  1. I affirm that the information provided on this application is true and complete.
    I understand that before I begin my volunteer service, I will complete the application requirements, submit a reference check, attend orientation, and any subsequent training sessions.
  2. I understand that this application does not guarantee a volunteer placement at Stormont-Vail and that if accepted, I will not receive payment for my service.
  3. I further understand by signing this agreement, I give permission to Stormont-Vail to contact references, to check driving and/or criminal background if deemed appropriate. I understand I may have to give additional information to Stormont-Vail to secure such records.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature*
 Your signature is required.

Date*
Please provide the current date.Invalid format must be mm/dd/yy.

Confidentiality Statement

If selected to become a Stormont-Vail HealthCare volunteer, I understand the necessity of maintaining, as privileged and confidential, all information which I may learn about SVHC patients, including, but not limited to, patient diagnoses, courses of care and treatment, prognoses, personal lives, relationships and concerns, family matters and all information contained between patients and SVHC staff, between patients and volunteers, or between physicians, and SVHC staff in regards to any patient.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature*
 Your signature is required.

Date*
Please provide the current date.Invalid format must be mm/dd/yy

Background and Verification Disclosure

Stormont-Vail HealthCare conducts background record checks. Failure to divulge complete information may disqualify you from volunteering. However, a conviction will not necessarily disqualify an applicant from applying.

As part of the volunteer placement process, Stormont-Vail HealthCare may obtain a Consumer Report and/or an Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Report Reform Act of 1996 requires that we advise you that for purposes of volunteering only a Consumer Report may be made which may include information about your character, general reputation, personal characteristics or mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided to you in the event the Report contains information regarding your character, general reputation, personal characteristics or mode of living.

Authorization and Release
During the application process, and at any time during my service as a volunteer, I hereby authorize Universal Background Screening on behalf of Stormont-Vail HealthCare, to procure a Consumer Report, which I understand may include information regarding my character, general reputation, personal characteristics or mode of living. This report may be compiled with information from court record repositories, departments of motor vehicles, past or present employers, educational institutions, governmental occupational licensing or registration entities, business or personal references and any other source required to verify information that I voluntarily supplied. In understand that I may request a complete and accurate disclosure of the nature and scope of the background verification to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature*
 Your signature is required.

Last Name, First Name, Middle Initial*
Please provide us with your last, first and middle initial.

 Date of Birth*
Please provide the current date.Invalid format must be mm/dd/yy.
Previous Legal Name (s)

Social Security Number

If selected to become a Stormont-Vail HealthCare volunteer, I understand the necessity of maintaining, as privileged and confidential, all information which I may learn about SVHC patients, including, but not limited to, patient diagnoses, courses of care and treatment, prognoses, personal lives, relationships and concerns, family matters and all information contained between patients and SVHC staff, between patients and volunteers, or between physicians, and SVHC staff in regards to any patient.

My typed name below shall have the same force and effect as my written signature.

Applicant's Signature*
 Your signature is required.

Date*
Please provide the current date.Invalid format must be mm/dd/yy.

For additional information or questions, please call Volunteer Services, 785-354-6095

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