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Volunteer Application Disclosure - LewisGale Flipbook PDF
Volunteer Application Disclosure Thank you for your interest in volunteering with LewisGale Hospital Pulaski. Attached p
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Volunteer Application Disclosure Thank you for your interest in volunteering with LewisGale Hospital Pulaski. Attached please find a Volunteer Application and the Disclosure and Release Form for your completion. Items to note:
Lewis Gale Hospital Pulaski has a policy of conducting background investigations for all Volunteer Applicants prior to beginning a volunteer experience, including High School Age, College Age, and Adult applicants.
Please complete all applicable information on the Volunteer Application.
On the Disclosure and Release Form, the line for “Any Other Names Used” refers to maiden names, adopted names, married names, etc.
If you have no employment history, please write “None” in that section of the Disclosure and Release Form.
If you are under the age of 18 years, the signature of a parent or guardian must be obtained and appear in the appropriate space on the Disclosure and Release Form.
Submit all pages of the Volunteer Application and the Disclosure and Release Form by mail: LewisGale Hospital Pulaski, Attn: Volunteer Services, PO Box 759, Pulaski, VA 24301. You can also drop off your application at the volunteer desk located in the main lobby.
Falsification of information on either the Volunteer Application or the Disclosure and Release Form, may be grounds for denial of a volunteer placement.
Background investigations will be conducted only on those applicants offered a volunteer position.
The Hospital is not obligated to provide a volunteer placement, nor is the Applicant obligated to accept a position, if offered.
ADULT AND COLLEGE STUDENT VOLUNTEER APPLICATION
Name: _____________________________ Date: ______________________________ Address: ____________________ City:
Phone: ____________________________
_______________________ State: _________ Zip: __________________
Email Address: __________________________________________________________ Person to notify in case of an Emergency: Name: _________________________________ Phone: ________________________ Address: ______________________________ Relationship: ___________________
Experience (Volunteer and Paid) Name of Business
Position Held
Dates
1.
__________________
________________________
__________________
2.
__________________
________________________
__________________
3.
__________________
________________________
__________________
References: List 2 people other than relatives or previous employers, who know your capabilities. Name
Phone
Relationship
_____________________ ___________________
_________________________
2. _____________________ ___________________
_________________________
1.
Were your referred by anyone: ____ Yes ____ No
If yes, by whom __________________
Volunteer Service Area: Please check the area(s) of the hospital in which you would like to volunteer. _____ Nursing Unit
______ Skilled Nursing Unit
_____ Information Desk
______ Support Services (Office areas)
_____ Emergency Department
______ Dietary
_____ Admissions/Patient Registration
______ Other __________________
Service Time: Please indicate what days and hours you are available to volunteer? Regular shift times for the information desk are: 9 am - 12 noon, 12 - 3 pm, 3 - 6 pm, 6- 9pm. Other service area hours are flexible. Day ____ Monday ____ Tuesday ____ Wednesday
Preferred Shift Hours 9-12 12-3 3-6 6-9 9-12 12-3 3-6 6-9 9-12 12-3 3-6 6-9
Day _____ Thursday _____ Friday _____ Saturday
Preferred Shift or Hours 9-12 12-3 3-6 6-9 9-12 12-3 3-6 6-9 9-12 12-3 3-6 6-9
Would you be willing to be on a substitute list to be called if another volunteer is unable to come in for his/her scheduled shift? _____ Yes ____ No If yes, what days and hours could you substitute? _______________________________________________________________________
Would you like to help with special projects that come up time to time such as community health screenings, fund raisers, etc.? _____ Yes _____ No What hobbies, skills, or talents do you have? _______________________________________________________________________ _______________________________________________________________________
Why do you want to become a LewisGale Hospital-Pulaski volunteer? ________________________________________________________________________ ________________________________________________________________________
Signature: _______________________________________ Date: __________________ Your signature indicates your approval for us to check your references. The organization is not obligated to provide a placement, nor are you obligated to accept the position offered.
LewisGale Hospital Pulaski ∙ PULASKI, VIRGINIA
24301
Junior Volunteer Application Form Name: ____________________________________ Today’s Date: ______________________ Address: __________________________________ Phone: ____________________________ Soc. Sec. #: ________________________________ Month & Date of Birth: ______________________ Are you 15 or older? ________________
Person to notify in Case of Emergency (Name, Address, Phone Number): ______________________________________________________________________________ Family Doctor: _____________________________ Phone: ____________________________
Paid Work Experience (Begin with most recent job): Name of Employer
Position Held
Dates
1. _________________________
_________________________
__________________
2. _________________________
_________________________
__________________
3. _________________________
_________________________
__________________
Volunteer Experience: Name of Organization
Position Held
Dates
1. _________________________
_________________________
__________________
2. _________________________
_________________________
__________________
3. _________________________
_________________________
__________________
Education (Begin with most recent school): Name of School
Degree and Year received
1. _____________________________________
_________________________________
2. _____________________________________
_________________________________
3. _____________________________________
_________________________________
Are you volunteering to fulfill a course requirement at school? ________________________ What hobbies, skills, or talents do you have? _______________________________________
References: List two people 18 or older, other than relatives, who know your capabilities. Name
Phone
Relationship
1. _________________________
____________________________
____________________
2. _________________________
____________________________
____________________
Have you ever been convicted of a criminal offense other than traffic violations? ___________ Where you referred by anyone? _____ Yes _____ No If yes, by whom? ___________________ How did you find out about our volunteer program? ___________________________________ Volunteer Service Area: Please check the activities that you would like to perform. Please be as selective as possible. _____ Read to patients ____ Play games with patients _____ Write cards/letters for patients _____ Share meals with patients _____ Assist radiology staff _____ Assist on nursing units _____ Assist the Cancer Center Staff _____ Staff the front information desk _____ Maintain coffee service/magazines in waiting rooms for visitors _____ Assist Physical Therapy staff _____ Assist emergency room staff _____ Other (please specify) _______________________________________________________ Are there any departments in the hospital that you would like to learn about through volunteering? ________________________________________________________________________________ Service Time: Volunteers typically serve once a week for one to three hours a week. Please state the day(s) and hour(s) you are available to volunteer (Regular shifts for the front desk are 9-12, 12-3, 3-6, and 6-9). ___________________________________________________________ Some volunteer needs are short-term while others are ongoing. To help us place you, please explain how long you expect to be a regular, active volunteer. A few weeks? A few months? Longer? _________________________________________________________________________________
Volunteer should have certain expectations regarding the way the hospital will treat them. The hospital recognized that volunteers want to feel important to the hospital and pledges to make every reasonable effort to accommodate the interests and ambitions of its volunteers. Please explain what you hope to get from your experience as a volunteer at LewisGale Hospital Pulaski. _________________________________________________________________________________
The hospital has a certain expectations regarding volunteers. Please read the following and sign you name by each one, signifying that you understand and are willing to meet the stated expectations or responsibility. The hospital expects that volunteers give conscientious considerations to their decision to volunteer. Volunteers should be prepared to give a good-faith effort in fulfilling their commitment to the department for which they volunteer. Volunteers are responsible for working their regularly scheduled hours and recording their attendance. Volunteers are responsible for notifying the Volunteer Coordinator and their area supervisor if they plan to be absent for a scheduled shift and for scheduling a fellow volunteer to replace them. _________________________________________________________________________________ Volunteers are responsible for following the hospital’s dress code. Volunteers must wear a shirt or jacket, provided by the hospital, and a picture ID that identify them as volunteers. _________________________________________________________________________________ The mission of Volunteer Services is in part to provide services to patients, visitors, and employees. Volunteers are expected to provide good customer service to patients and visitors as well as to hospital employees and to accept supervision graciously. Volunteers are expected to treat visitors and patients with consideration; a smile, a “thank you,” a friendly greeting, or an offer of assistance brightens someone’s day.
The mission of Volunteer Services is also to promote community understanding of the hospital. Volunteers are expected to approach their responsibilities in a spirit of learning.
Please state any questions or reservations you have about any of the expectations or responsibilities listed above. _________________________________________________________________________________
_________________________________________________________________________________ There are many organizations in the area that accept volunteers. Why do you want to volunteer at LewisGale Hospital Pulaski? _________________________________________________________________________________
_________________________________________________________________________________ Please return completed application to: Volunteer Services Office LewisGale Hospital Pulaski 2400 Lee Highway Pulaski, VA 24301
Dear Parent(s): Your child has expressed an interest in serving as a Junior Volunteer with LewisGale Hospital Pulaski. With your approval, we would be very pleased to accept your child as a member of the teenage volunteer group. Junior Volunteers perform many important tasks in the hospital, as well as helping to create a cheery atmosphere for patients and staff. Functioning in these capacities, they become sensitive to the needs and problems of the ill and disabled, and learn the responsibility and satisfaction of service to others. Sincerely, Jana Beckner, Director HR & Volunteer Services
-------------------------------------------------------------------------------------------------------------------------
CONSENT FORM: To: LewisGale Hospital Pulaski
My child _______________________________________, has my consent to serve as a Junior Volunteer with LewisGale Hospital Pulaski.
_______________________________________________ Signature of Parent
_______________________________________________ Date
CONSUMER AUTHORIZATION I. I understand that an investigative report may be generated on me that may include information as to my character, general reputation, personal characteristics, or mode of living; work habits, performance or experience, along with reasons for termination of past employment/professional license or credentials; financial/credit history; or criminal/civil/driving record history. I understand that General Information Services, Inc. (GIS), on behalf of HCA or one of its affiliates may be requesting information from public and private sources about any of the information noted earlier in this paragraph in connection with HCA or one of its affiliates’ consideration of me for employment, promotion or position re-assignment or contract now, or at any time during my tenure with HCA or one of its affiliates, and give my full consent for this information to be obtained. II. IF APPLICABLE, medical and worker’s compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. III. According to the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), I am entitled to know if the considerations for which I am applying are denied because of information obtained from a consumer reporting agency. If so, I will be notified and be given the name of the agency providing that report. IV. I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state and county agencies. V. I understand that if I am a resident of Minnesota/Oklahoma (only) I may obtain a copy of the report ordered, and now indicate my desire to do so by checking this box . VI. I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or insurance company contacted by GIS to furnish the information described in Section I. VII. Upon proper identification, you have the right to make a request to GIS, within a reasonable period of time, as to the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that GIS has previously furnished. Communications with GIS should be directed to PO Box 353, Chapin SC 29036 or (866) 265-4917.
CANDIDATE COMPLETE THE FOLLOWING: ___________ Signature
__
___________ Please print full name
__
Today’s Date ________ Phone Number
______________________________________________ Parent Signature
Email Address
The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.
Month, Day and Year of Birth
Social Security Number
Home Address
City
Driver’s License Number and State
State
Zip
Name as it appears on License
________________________________________________________ Please provide all alternate name(s) used (Maiden names, former married names, etc.) Have you ever been convicted of a crime? __ No details of conviction.
__ Yes
If yes, please provide city, county, state, date of conviction and
_____________________________________________________________________________________________________ Previous Addresses for the Last 7 Years (use additional page if needed)
Street Address
City
State
Zip
Street Address
City
State
Zip
Street Address
City
State
Zip