Welcome to Stormont-Vail Volunteer Services

Youth Volunteer Application Form

Please complete ALL fields before clicking the button to submit.

YOUTH Volunteer Eligibility Requirements

Application and Eligibility Requirements
These requirements are provided at no cost to the volunteer except for #4

1. Minimum age 14 and attending middle, high or home school
2. Physically, mentally and emotionally able to perform duties assigned
3. A minimum four month commitment
4. Purchase the approved volunteer uniform $23
5. Complete application which includes confidentiality statement, parental consent and a reference request
6. Provide completed copies of the following and bring at time of interview:
- Health assessment
- Flu consent
- Immunization form
- Reference
- Most recent grades
7. Attend an interview with a Volunteer Services representative.
8. Upon acceptance meet with the hospital's employee health nurse to:
- Review the health assessment forms (forms listed above)
- Review copy of immunizations (provided by applicant)
- Receive a mandatory tuberculin skin test which requires a small blood sample - at no charge
- Receive flu vaccination (Sept. - May) - at no charge
9 . Complete new volunteer orientation prior to the 1st day of volunteering

YOUTH Volunteer Application

***If a field is not applicable please type N/A in the box.

Personal Information

* First name*

* Middle name*

* Last name*

* Preferred first name*

* Date of birth*

Gender*

* Home Address*

* City*

* State*

* Zip/postal*

* Cell phone*

* Home phone*

* Work phone*

Best contact phone*

Email: (Primary email will be used to communicate schedules and other important information. Alternate email address will be used if primary email does not respond). For email changes, notify 354-6095.

* Primary E-mail*

Primary Email Ownership

* Alternate E-mail (if under 18 years of age)*

Alternate Email Ownership

* Name, if not applicant:

* Alternate phone (if under 18 years of age)*

Alternate Phone Ownership

* Name, if not applcant:

* School Name:

Emergency Contact

* Name*

* Relationship*

* Address*

* City*

* State*

* Zip/postal*

* Cell Phone*

* Home phone*

* Work Phone*

Best contact phone*

* E-mail

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?*

* Please explain any conditions or limitations which may affect your ability to volunteer.*

* Indicate the reason you are seeking a volunteer position.*

What minimum commitment can you make?*

Volunteer Services will provide a letter of recommendation for scholarships, if the volunteer has fulfilled the required time commitment and satisfactorily performed their volunteer duties. Request must be made at least two weeks prior to the date needed.Verification of a volunteer's length of service will be provided to a potential employer however, personal references will not be given.

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

Consent Agreement

As part of the volunteer placement process, and at any time during my service as a volunteer, I hereby authorize Universal background Screening on behalf of Stormont Vail Health, to procure a Consumer Report, which I understand may include information regarding my character, general reputation, personal characteristics or mode of living. This report may be compiled with information from court record repositories, departments of motor vehicles, past and present employers, educational institutions, governmental occupational licensing or registration entities, business or personal references and any other source required to verify information that I voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification to the extent such investigation includes information bearing onmy character, general reputation, personal characteristics or mode of living.

Completion of this application process certifies that all information you have provided herein is correct to the best of your knowledge and belief. You understand all statements could be verified and that the making of a false statement herein, or the omission of any material fact, may result in your immediate discharge from Stormont Vail Health.

Medical screenings, including but not limited to immunity and tuberculosis blood testing, required for volunteering will be requested only if a volunteer position is offered by Stormont Vail Health. You agree that the pre-volunteer screening required by Stormont Vail Health is completed with your consent and that all volunteer offers are contingent upon successful completion of this pre-volunteer screening process.

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.

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

* Parent/Guardian Signature

* Date

* Applicant's Signature

Date

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.