Volunteer Application Form

Volunteer Eligibility Requirements

These requirements are provided at no cost to the volunteer except for #4

Minimum age of 18
Physically, mentally and emotionally able to perform duties assigned
A minimum four month commitment
Purchase the approved volunteer uniform
Complete application which includes confidentiality statement and photo release
The following forms will need to be completed prior or at time of interview (Click the link to download)
1. Background Check Form
2. OIG-EPLS Form
Attend an interview with a Volunteer Services representative.
The following forms will need to be completed and brought to Health Assessment. If unable to print will be provided at interview:
1. Review copy of immunizations (provided by applicant)
2. Receive a mandatory tuberculin skin test which requires a small blood sample - at no charge
3. Receive flu vaccination (Sept. - May) - at no charge
Complete new volunteer orientation prior to the 1st day of volunteering.

Note: Stormont Vail does not recognize volunteer hours for court mandated reporting.

Any field that is yellow or has a red asterisk need to be filled out, enter "N/A" if not applicable.

Requirements Agreement

I agree to the above listed requirements

Volunteer Location

Please select the location you are looking to volunteer at.

Personal Information

* First name

Middle name

* Last name

Preferred first name

* DOB

Gender

* Home Address Line 1

Home Address Line 2

* City

State

* Zip/postal

* E-mail

Best contact phone, select all that apply.

Home

Cell

Work

* Cell phone

* Home phone

* Work phone

Emergency Contact

* Name

* Relationship

* Address Line 1

Address Line 2

* City

State

* Zip/postal

* Email

Best contact phone, select all that apply.

Home

Cell

Work

* Cell phone

* Home phone

* Work phone

Education and Skills

Education Status

Current College enrolled in.

* If your college is not listed please list below.

* Current Year in School

* Major

* Degree(s)

List any additional training, classes, skills, and/or certifications

Professional and Personal History

Are you currently employed by Stormont Vail?

* Position Title

* Department name(s)

Are you a Veteran?

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 'N/A' in the box )

* Please explain any conditions or limitations which may affect your ability to volunteer. (If none please type 'N/A' in the box)

* Indicate the reason you are seeking a volunteer position. (If none please type 'N/A' in the box)

What minimum commitment can you make?

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

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.

* If 'I do not agree', why?

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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 volunteerdept@stormontvail.org or (785) 354-6095.