ADENA VOLUNTEER APPLICATION

PERSONAL INFORMATION

Year Round Resident

EDUCATION

WORK STATUS

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Provide name, address, phone and years worked.

Skills/Work Experience (Check all that apply)

IN CASE OF EMERGENCY CONTACT

How Did You Hear About Our Program?

Select a choice
Have you ever been convicted of a crime?

AVAILABILITY AND BACKGROUND

Please complete the following to determine your availability and for a background check.

Service Area Opportunities (check all that apply):
Availability (check all that apply)

ATTESTATION AND CONFIDENTIALITY

Attestation

The information contained in this application is true in all aspects, without any willful omissions. I understand that if this application is false in any way, I will be dismissed without notice regardless of when the false information is discovered.

As a volunteer, I:

  • Agree to complete the volunteer orientation and train until I am competent to perform the required duties.
  • Agree to complete an annual compliance review and TB screening as well as any additional service specific training that may be deemed necessary.
  • Agree to comply with all rules and regulations of Adena Health system and to uphold the policies of my volunteer organization.
  • Understand that I may be dismissed from my duties for willful wrongdoing or negligence and or performing duties outside of my service guidelines.
  • Agree to call the Volunteer Scheduling Secretary or Director of Volunteer Services as soon as possible when I have scheduling changes.
  • Agreed to except assignment to a new service area if absent for an extended period of time.

Confidentiality

It is the belief of this hospital that all medical financial and personal information pertaining to a patient is confidential and is protected from unauthorized viewing discussion and disclosure. Therefore volunteers may look at use or disclose patient information only as it relates to the performance of their duties. Any unauthorized viewing discussion or disclosure will provide grounds for immediate dismissal. Whenever it is questionable as to what information is confidential it is your responsibility to discuss the matter with your supervisor before any breach of confidentiality occurs.

Type your name to "sign" your application.

Authorization for a minor:

I have read the above information and give my permission for the application to become a volunteer and to receive the required tuberculin test is required. I will cooperate in saying that my son/daughter fulfills his/her responsibility.

Type your name to 'sign" your authorization of a minor.