Mon Health System - Student Volunteer Application

Student Volunteer Application


Name:
Address:
City:
State:
Zip:
Daytime Phone:
E-mail Address:
Birthdate:
SS No.:


EMERGENCY CONTACT:
Name:
Relationship:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:


CURRENT COLLEGE/UNIVERSITY:
College/University:
Course of Study:


PRIOR VOLUNTEER EXPERIENCE:

1. Have you ever been convicted of a crime? Yes No
If yes, explain when, where and disposition of the case.

2. Limitations related to health:


3. Special Skills, Training, Interests or Hobbies that may apply to your volunteer experience:


4. How did you become interested in the Mon Health System Volunteer Program?


5. Service area desired:

AVAILABILITY (please check all that apply and list times where applicable):
	MON	TUES	WED	THUR	FRI	SAT	SUN
Morning
Afternoon
Evening


REFERENCES:
Reference One
Name:
Relationship:
Address:
City:
State:
Zip:
Work Phone:

Reference Two
Name:
Relationship:
Address:
City:
State:
Zip:
Work Phone:

Believing that Monongalia Health System has need of my services as a Volunteer worker, I agree to: Hold as absolutely confidential ALL information which I may obtain directly or indirectly concerning patients, doctors or personnel and I will not seek out confidential information in regard to a patient. My services are donated to Monongalia Health System without contemplation of compensation or future employment and given with humanitarian or charitable reasons. APPLICANT SIGNATURE: . DATE: 03/18/2010 · 05:07PM Opportunities for Volunteers are provided without regard to religion, creed, race, national origin, age, sex or disability. NOTE: Filing out an application does not assure placement since the number of applicants usually exceeds the number of available openings. Applicants will be chosen on the basis of qualifications in keeping with the best interest of the Monongalia Health System. The first month of Volunteer experience will be mutually probationary. All applications will be kept on file for ninety (90) days.