Volunteer Profile

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

Name of person to contact in case of emergency

Relationship to you

Phone

Please list any relatives employed at Stormont-Vail:

Name

Relationship

Department

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?

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:

Current School

Phone

School attending next year if different from above:*
Name

Phone

Current Grade

Activities: (Clubs, sports, etc.)

Hobbies and other interests

Art

Crafts

Computer

Clerical

Typing

Journalism

Other

Academic School Year

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

1. I affirm that the information provided on this application is true and complete.
2. I understand that before I begin my volunteer service, I will complete the application requirements, schedule an interview, attend orientation, and any subsequent training sessions.
3. 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

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

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

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