Adult Volunteer Application - Hartford Hospital!

Adult Volunteer Application
Personal
Last Name First Name Mr / Mrs / Ms Preferred 1st name
Address Apt. # City State Zip home Phone
Business Phone Cell Ph. / pager e-mail date of birth
(year optional)
Education
Circle Highest Grade completed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
College
Post Graduate
If currently a student, name of school:________________________________________________________________
Field of study______________________________________Licensure/certificates_____________________________
Other Volunteer experience______________________________________________phone_______________________
Position Held_____________________________________Contact Name_______________________________________
Reference Information
Spouse Name (if applicable) __________________________________________________
In case of Emergency,contact :_______________________________________________________________________________
Address_______________________________________day phone_______________________evening_______________________
Physician’s name___________________________________Ctiy_________________________phone________________________
Reference (non relative) ___________________________________________Relationship_____________________________
Years Known___________day phone__________________________________evening phone____________________________
Employment history
(Begin with current or most recent)
Employer ______________________________________________________________Years Employed____________
Position held___________________________Supervisor________________________phone__________________
Employer ______________________________________________________________Years Employed____________
Position held___________________________Supervisor________________________phone__________________
** REQUIRED **
From our list of current openings please indicate the specific role for which you are Applying.
Failure to indicate a specific role may delay the processing of your application.
Department_______________________________________________Role_______________________________________________
Department_______________________________________________Role_______________________________________________

How did you hear about our program?_____________________________________________________________________
______________________________________________________________________________________________________________
Are you interested in other volunteer opportunities at Hartford Hospital? If so please list the
Hours you are available: M_________T__________w__________Th__________F__________S__________Su__________
Languages spoken that you would be willing to utilize as a volunteer?_________________________________
Special Interests/Hobbies/Talents________________________________________________________________________
Computer Skills (list specific programs) ___________________________________________________________________
What do you hope to accomplish through volunteer work?_______________________________________________
Are you required to do court-ordered Community Service? [ ] Yes [ ] No If yes, how many hours? _________
By When? _____________ What was the charge?_____________________________________________________________________
(failure to provide this information prior to beginning your volunteer service will result in non-documentation of service)
If accepted as a volunteer at Hartford Hospital, I agree that:
1. I will hold confidential all information that I may obtain directly or indirectly concerning patients or personnel, and not seek
to obtain confidential information from a patient.
2. Under no condition will I provide medical assistance or advice to a patient, visitor or staff member.
3. I will fulfill my commitment to the hospital (3 hours/week for 6 months) by completing all assignments that I accept.
4. I will make my best effort to resolve any problems related to my volunteer activities with my supervisor, and if unsuccessful,
strive to resolve such problems with the Volunteer Services staff.
5. I will notify my immediate supervisor if I am unable to work as scheduled.
6. I will submit documentation of the MMR (Measles/Mumps/Rubella) series to Volunteer Services. documentation of
a Tuberculosis test done within the last 12 months will be submitted prior to beginning volunteer service, and an annual re-test
may be necessary depending on the location of the volunteer assignment. I understand that if my TB test is positive I will need to
have further testing done by my own physician at my own expense and provide a physician’s letter stating the findings.
7. I will not sell goods or services, request contributions, or distribute political or religious materials on hospital premises.
8. My services are donated to the hospital without contemplation of compensation or future employment.
9. I understand that the Volunteer Services Department reserves the right to terminate my volunteer status as a result of, 1)
failure to comply with hospital policies, rules and regulations; 2) absences without prior notification; 3) unsatisfactory attitude,
work or appearance; or 4) any other circumstances which, in the judgment of the Director of Volunteer Services, would make my
continued service as a volunteer contrary to the best interests of the hospital.
10. I agree to abide by the policies of Hartford Hospital and the Department of Volunteer Services, including Sexual Harassment,
Disciplinary Policy/Rules of Conduct, and Safety.
I have read each of the above conditions and I agree to be bound by them.
______________________________________________________________________ _______________________
Signature
Date
The following information is used only to determine diversity of Hartford Hospital volunteers. Completion is
optional . please check one: [ ] white (not Hispanic) [ ] Black (not Hispanic) [ ] Hispanic
[ ] asian or pacific islander [ ] American Indian/Alaskan native
signature _________________________________________________________ date__________________
Office use only
REV. 07/2011
KB EP EE Direct

Volunteer Application Health Form
Applicant Name:
(please print)
Please attach documentation from your physician about status of: 1) MMR vaccine, 2)
chicken pox vaccination or history of disease, and 3)Tuberculosis screening or BCG
vaccination (see options below).
Failure to provide this documentation will result in us being unable to consider you
for placement as a volunteer.
Regarding the Tuberculosis Screening:
One Tuberculosis skin test (PPD or tine test) performed within the last 12 months is a
REQUIREMENT for volunteering at Hartford Hospital.
Please check the following that applies to you:
[ ] I Have attached documentation of a BCG vaccine.
[ ] I have attached documentation of a Tuberculosis test (PPD or tine test) that was
Done within the past 12 months and was negative.
[ ] I have attached documentation of a Tuberculosis test (PPD or tine test) that was
positive, and have also attached documentation of a chest x-ray that was done in
follow-up and was negative.
[ ] I have not had a Tuberculosis test done within the last 12 months but will make an
appointment to do so either with my own physician or with the department of
Occupational Health at Hartford after I have been accepted into a volunteer role.
REV. 07/2011
Department of Volunteer Services