Welcome to Stormont-Vail Volunteer Services

College Volunteer Application Form

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

1. High school graduate attending vocational or technical school, college, or university.
2. Physically, mentally and emotionally able to perform duties assigned
3. A minimum six month commitment (except summer program)
4. Purchase the approved volunteer uniform ($20-28, depending on selection)
5. Complete application which includes confidentiality statement, background check information
6. Provide completed copies of the following and bring at time of interview:
· Health assessment (please print and complete hard copy and bring to interview)
· Flu consent (please print and complete hard copy and bring to interview)
· Immunization form (please print and complete hard copy and bring to interview)
· Social Security number information for Background check (please print and complete hard copy and bring to interview)
7. Attend an interview with a Volunteer Services representative.
8. Upon acceptance, meet with the hospital's employee health nurse to:
· Review the health assessment forms (forms listed above)
· Review copy of immunizations (provided by applicant)
· Receive a mandatory tuberculin skin test which requires a small blood sample - at no charge
· Receive flu vaccination (Sept. - May) - at no charge
9. Complete new volunteer orientation prior to the 1st day of volunteering.

COLLEGE 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*
DOB*
Gender
Home Address*
E-mail*
City*
State*
Zip/postal*
Cell phone*
Home phone*
Work phone*
Best contact phone*

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

Education and Skills
High School Graduate
Current College Student
Current Year in School
Major
Degree(s)
College Graduate
List any additional training, classes, skills

Professional and Personal History
Are you currently employed by Stormont Vail?*
Volunteer Interest and History
Have you ever been a Stormont Vail Volunteer?*
Previous Volunteer Experience: (If volunteer at SVH, list past areas)*

(If none please type "None" in the box)
Please explain any conditions or limitations which may affect your ability to volunteer.*
Indicate the reason you are seeking a volunteer position.*
What minimum commitment can you make?*
Volunteer Services will provide a letter of recommendation for scholarships, if the volunteer has fulfilled the required time commitment and satisfactorily performed their volunteer duties. Request must be made at least two weeks prior to the date needed. Verification of a volunteer's length of service will be provided to a potential employer however, personal references will not be given.

Are you legally eligible to reside in the United States?*
*** Please note we do not accept applications seeking court mandated community service hours.
Have you ever been convicted of a misdemeanor or have charges pending? (This would include traffic violations)*
If yes, please explain.*
Have you ever been convicted of a felony or have charges pending? (This would include traffic violations)*
If yes, please explain.*
(Stormont Vail Health conducts criminal record checks. Failure to divulge complete information may disqualify you from volunteer service. However, a conviction will not necessarily disqualify an applicant from applying).

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
To digitally sign this message type your full legal name in UPPERCASE:*
Date

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 or present employers, educational institutions, governmental occupational licensing or registration entities, business or personal references and any 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 on my 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*
Applicant's Signature*
Date*
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 volunteerdept@stormontvail.org or (785) 354-6095.