Welcome to Stormont-Vail Volunteer Services

Returnee Volunteer Application Form

Please complete ALL fields before clicking the button to submit.
RETURNEE Volunteer Eligibility Requirements
Application and Eligibility Requirements
These requirements are provided at no cost to the volunteer except for #4

1. Minimum age 14
2. A six month commitment (except summer program)
3. Purchase the approved volunteer uniform ($20-28, depending on selection)
4. Completion of Returnee application.
5. A current health assessment and TB skin test (requires a small blood sample) within one year of last volunteer hours recorded.
6. Complete the annual Education Module provided by Volunteer Services, if more than one year since last volunteer hours recorded.
7. Attend an interview with Volunteer Services to determine placement, if more than two years since last volunteer hours recorded.
8. Attend new volunteer orientation, if more than two years since last volunteer hours recorded.
9 . Current background check (if over 18 years of age), if more than one year since last volunteer hours recorded.
RETURNEE Volunteer Application
***If a field is not applicable please type N/A in the box.

Personal Information
First name*
Middle name*
Last name*
Preferred first name*
Date of birth*
Gender*
Home Address*
City*
State*
Zip/postal*
Cell phone*
Home phone*
Work phone*
Best contact phone*
Email: (Primary email will be used to communicate schedules and other important information. Alternate email address will be used if primary email does not respond). For email changes, notify 354-6095.
Primary E-mail*
Primary Email Ownership
Alternate E-mail (if under 18 years of age)*
Alternate Email Ownership
Name, if not applicant:
Alternate phone (if under 18 years of age)*
Alternate Phone Ownership
Name, if not applcant:

Emergency Contact
Name*
Relationship*
Address*
City*
State*
Zip/postal*
Cell Phone*
Home phone*
Work Phone*
Best contact phone*
E-mail

Are you currently employed by Stormont Vail?

Confidentiality Statement
If selected to become a Stormont Vail Health volunteer, I understand the necessity of maintaining, as privileged and confidential all information which I may learn about SVH 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 SVH staff, between patients and volunteers, or between physicians, and SVH staff in regards to any patient.
My typed name below shall have the same force and effect as my written signature.
Yes, I agree to these terms
Date
To digitally sign this message type your full legal name in UPPERCASE:*
Consent Agreement
As part of the volunteer placement process, and at any time during my service as a volunteer, I hereby authorize Universal background Screening on behalf of Stormont Vail Health, 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 and 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. I 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 onmy character, general reputation, personal characteristics or mode of living.

Completion of this application process certifies that all information you have provided herein is correct to the best of your knowledge and belief. You understand all statements could be verified and that the making of a false statement herein, or the omission of any material fact, may result in your immediate discharge from Stormont Vail Health.

Medical screenings, including but not limited to immunity and tuberculosis blood testing, required for volunteering will be requested only if a volunteer position is offered by Stormont Vail Health. You agree that the pre-volunteer screening required by Stormont Vail Health is completed with your consent and that all volunteer offers are contingent upon successful completion of this pre-volunteer screening process.
Publication and Photo Release:
I give my consent to Stormont Vail Health to make and use images of me for internal use (hospital newsletters, recognition events, website, televised/commercial programming). I understand that there will be no remuneration paid to me or anyone related to me for the uses of these images.

My typed name below shall have the same force and effect as my written signature*.
Yes, I agree to these terms.
To digitally sign this message type your full legal name in UPPERCASE
Parent/Guardian Signature (if applicant is under 18 years of age)
Date

Date
Applicant's Signature
Upon submission of your application you will be contacted by the volunteer office within two to three business days. If you have questions please contact us at (785) 354-6095 or email volunteerdept@stormontvail.org.