Youth Volunteer Application Form

Youth Volunteer Eligibility Requirements

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

Minimum age 14 and attending middle, high or home school
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
Provide completed copies of the following and bring 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

* Date of birth

* Current Age

Gender

* Home Address Line 1

Home Address Line 2

* City

State

* Zip/postal

Communication Preference

Email

Phone

Best contact phone, select all that apply.

Home

Cell

Work

* Cell phone

* Home phone

* Work phone

Email will be used to communicate schedules and other important information.

* E-mail

Parent/Guardian Information

Please provide a parent or legal guardians contact information.

* Parent or Guardian's name

* Parent or Guardian's email

* Parent or Guardian's phone number

School Information

School name

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

Professional and Personal History

Have you ever been employed by Stormont Vail?

* Department name(s)

* Position Title

Hobbies and Other Interests

Volunteer Interest and History

Have you ever been a Stormont Vail Volunteer?

* Previous Volunteer Experience (If volunteered at Stormont Vail, list past areas):

Are there any groups you are not comfortable working with?

* If yes who are they?

* Indicate the reason you are seeking a volunteer position.

What minimum commitment can you make?

Parental/Guardian Sign Off

Please provide a name and email address for your parent/guardian. Once you submit the application an email is going to be sent to the parent/guardian you list below. They are going to be asked to sign off that you are allowed to volunteer with us.

* Parent/Guardian Name

* Parent/Guardian Email:

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.

* Yes, I agree to these terms

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

* Date

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Applicants 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.