Volunteer Profile

We are now accepting applications for the Fall & Winter program.
Please call Volunteer Services at (785) 354-6095 for more information.
Thank you.

Fall/Winter Program runs from Sept. 15 through Feb. 1
Summer Program begins the first week of June

Youth Applicant (Must be at least 13 years of age.)
The applicant has two submission options. You may either submit the following application electronically, then bring the following supporting materials the day of the interview: 1) a letter of recommendation of a teacher or counselor, 2) a copy of your recent grade report, and 3) MMR (measles, mumps, rubella) immunity documentation of two (2) vaccinations. Or, you may send the application and supporting documents, via regular mail, to Stormont-Vail Regional HealthCare, 1500 SW 10th Avenue, Topeka, Kansas 66604-1353. Applicants choosing the latter option need not bring supporting documents the day of the interview.

Full Name
(First, Middle, Last)

Date of Birth

Age

Address

City

State

Zip

Applicant's Email Address

Home Phone

Work Phone (if applicable)

Best days and time to contact you

Last Four Numbers of Your Social Security #

Parent/Guardian (Father)	Work Phone	Home Phone
Parent/Guardian (Mother)	Work Phone	Home Phone

Emergency Contact (if different from names listed above)

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? 3 months 6 months 12 months or longer Other

Do you have transportation?

How did you learn about Stormont-Vail?

friend	employer	instructor	co-worker	clergy	radio
television	newspaper	poster/flyer	newsletter	Other

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

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

List any previous work experience:

List any previous volunteer experience:

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

List any organizations of which you are currently a member:

Schools, Hobbies & Other Interests

Current School		Phone
School attending next year if different from above: Name		Phone

Current Grade	Activities: (Clubs, sports, etc.)
Hobbies and other interests

Reference
Applications without complete reference information will not be processed.
References must be current; do not use family members. The reference letter must accompany this application.

Name
Address		Phone

Skills and Interests

Art

Crafts

Computer

Clerical

Typing

Journalism

Other

Placement Information
Indicate program which you are applying and time schedules most suitable:

After School	Days		Summer Hours Available
Summer (Last day of School)	Sunday	Thursday	8:00am - 12:00pm
Last day of school	Monday	Friday	12:00pm - 4:00pm
Date available to begin?	Tuesday	Saturday	4:00pm - 7:00pm
	Wednesday		Other

Please read the following carefully and sign below

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.
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.

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

Applicant's Signature

Date

Parent/Guardian

I hereby authorize SVHC to medically treat or manage any injury sustained as described or identified in the Kansas Workers Compensation Statute, KSA 44-501, further authorize care to be given by professional representatives of Midwest Occupational Health Services or of the Emergency Department at SVHC. I also authorize participation in the tuberculosis screening/monitoring program as outlined per Kansas statutes and SVHC policies. Finally, I consent for my child to serve as a volunteer at SVHC and consider her/him capable of undertaking the responsibilities of a health center volunteer. I certify that he/she is at least 13 years of age.

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

Parent/Guardian Signature

Date

Address

Daytime Phone

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

Date

Uniforms (ordering purposes only)
Polo Shirt M L XL XXL

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

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