Volunteer Services Department Junior Volunteer Application

Please check hospital

Personal Information

Name and DOB

* Last name

* First name

Middle name

* DOB

Address:

* Line 1

Line 2

* City

State

* Zip/postal

Phone and Email:

Phone (Home)

* Phone (Mobile)

* E-mail

Emergency Contact:

* Contact name

* Relationship

Line 1

Line 2

City

State

Zip/postal

* Phone (Home)

* Phone (Mobile)

Allergies:

Indicate any allergies, health conditions, or disabilities, which may interfere with your ability to perform volunteer work.

Languages

Primary Language

Additional languages

General Information and Availability for Volunteering

Indicate preferences in assignment:

Patient

Non-Patient

Clerical

Are you available year round?

If no, when are you available?

Are you required to give hours for Community Service?

* If so, how many hours?

Are you currently seeking paid employment?

If yes, what type?

* Why are you interested in becoming a volunteer at Virtua Health?

How did you learn about the volunteer program at Virtua Health?

Availability

Days and Times Available to Volunteer (check all that apply):

Monday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Tuesday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Wednesday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Thursday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Friday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Saturday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Sunday

8 a.m. - Noon

Noon - 4 p.m.

4 p.m. - 8 p.m.

Work and Volunteer Experience

Are you currently employed?

Yes

No

Full Time

Part Time

Are you a Virtua employee?

1. Volunteer Agency

Volunteer Agency Name and Address

Supervisor Name

Email Address and Telephone Number

2. Volunteer Agency

Volunteer Agency Name and Address

Supervisor Name

Email Address and Telephone Number

References

This section must be completed References must be at least 18 years old and cannot be relatives or individuals residing in your household.

Personal/Professional Reference #1:

* Name

Title

* Phone

* E-mail

Relationship

Personal/Professional Reference #2:

* Name

Title

* Phone

* E-mail

Relationship

Primary Care Physician:

* Name

* Full Address (include City, State, Zip Code)

* Fax Number

High School Student Applicants

Parent or Legal Guardian

* Name of Parent of Legal Guardian

Line 1

Line 2

City

State

Zip

Phone (Home)

* Phone (Mobile)

School Information

Principal's Name

* High School Name

* Address 1

Address 2

* City

* State

* Zip/postal

Grade

* Guidance Counselor Name

* Title

* Phone

* E-mail

Interests/Skills

Please checkoff from the list below.

Other Clerical Skills

Other Patient Care Services

Other Personal Skills to Use or Teach

Musical Instrument

Do you have any additional Skill or Comments?

Additional Skills or Comments

Certification

AFTER COMPLETING THE APPLICATION, PLEASE READ CAREFULLY AND SIGN

We appreciate your interest in our hospital. A clear understanding of your background and work/volunteer experience will aid us in considering you for the volunteer position that best meets your qualifications and interests.

1. I give permission to Virtua Health to investigate any and all information concerning my application in order to determine my qualifications. This includes, but is not limited to medical clearance, criminal background checks, employment and personal reference checks, and educational or certification verification. I understand that any misrepresentation of facts contained in this application may be cause for my rejection or dismissal.

2. I agree to be photographed by the hospital.

3. I agree that any personal property carried by me from the hospital premises, including packages, briefcase, or any other hand luggage may be inspected by authorized personnel.

4. I agree to abide by all hospital rules and regulations. I understand that if placed, my placement will be subject to the conditions of any applicable introductory period established by hospital policies. I understand that this application and any other hospital documents are not contracts of employment, and that any volunteer who is placed may voluntarily leave under proper notice, and may be terminated at any time or for any reason.

5. In the event of my resignation or termination, I agree to return all hospital property loaned to me such as identification badges, uniforms, library books, keys, etc.

PLEASE NOTE

All Virtua volunteers are required to receive an annual influenza vaccine.

My signature below indicates that I have read, understood, and consent to the above statements. This authorization or photocopy shall serve as consent for the hospital to request any information concerning my application.

[ clear ]

Volunteer Signature