Volunteer Application Form - Boulder Community Hospital

P.O. Box 9019 Boulder, Colorado 80301-9019 Office 303-440-2137 Fax 303-938-3474
Volunteer Application Form
Last Name ___________________________________ First Name ______________________________ Today’s Date _______________________
Home Phone __________________ Work Phone (Ext.) __________________ Cell/Pager ____________________ E-mail ____________________
Street Address______________________________________ City __________________________________ State ________ ZIP____________
Categories (check all that apply) Year-Round Volunteer Summer Only Volunteer Adult Volunteer (18+) College Student Teen Volunteer (14–17)
Confidential / Personal Information
Birthday (Month/Day/Year) ____________________ Social Security No. _________________________ Driver’s License No._____________________
Emergency Contact 1 Last Name ___________________________ First Name ___________________________ Relationship_______________
Home Phone ___________________________ Work Phone (Ext.) ____________________________ Cell Phone ___________________________
Emergency Contact 2 Last Name ___________________________ First Name ___________________________ Relationship_______________
Home Phone ___________________________ Work Phone (Ext.) ____________________________ Cell Phone ___________________________
References_____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Medical Information (Optional)
Your Physician Name _____________________________ Phone ___________________________ Hospital of Choice________________________
If you need special assistance or accommodation to perform your volunteer duties, you may indicate those needs here, during your interview or any time in the future.
Special Needs __________________________________________________________________________________________________
Current or Last Employment
Employer’s Name ___________________________________________________________
Dates of Employment ____________________________
Occupation (Type of Work) ________________________________________ May we call you at work Yes No Best Times _________________
Employer Street Address ________________________________________________
Department or Suite Number_____________________________
City ___________________________________________ State _________________________________________ ZIP____________________
Prior Volunteer Service
Where else have you volunteered ____________________________________________________________________________________________
Duties______________________________________________________________
Agency ___________________________________________
Department ____________________________ Supervisor _________________________________ Phone _______________________________
Duties______________________________________________________________
Agency ___________________________________________
Department ____________________________ Supervisor _________________________________ Phone _______________________________
Do you have family members who are BCH volunteers BCH staff Name(s) _______________________ Department(s) _____________________
Have you served as a volunteer with us before No Yes If yes, in what year ____________ Department_________________________________
Interests & Preferences
I prefer to work Directly with patients In an office setting Both No preference Other ____________________________________________
Departmental preference _______________________________ How did you hear about our program _______________________________________
What do you envision yourself doing as a volunteer _______________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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P.O. Box 9019 Boulder, Colorado 80301-9019 Office 303-440-2137 Fax 303-938-3474
Volunteer Application Form, Page 2
Contract of Confidentiality
As a volunteer I understand that I may come in contact with confidential information, both clinical and employee related, through, but not limited to, written
records, documents, ledgers, internal correspondence and communications, computer programs and applications. I agree not to divulge or disclose to anyone
other than those persons of Boulder Community Hospital and/or its affiliates who have a “need to know,” directly or indirectly, either during or after my services,
any confidential information acquired during the course of my service. I understand and acknowledge that in the event I breach any provision of this agreement,
Boulder Community Hospital, in addition to other legal remedies available to them, has the right to reprimand, suspend and/or terminate my volunteer service.
Volunteer Name (print) ______________________________________
Volunteer Signature ___________________________________________
Background Checks
We consider the safety and security of children to be of the utmost importance. Applicants wishing to work in the following areas must complete a background
history form: Newborn photography, pediatric rehabilitation, and LifeLine. Women and Family Services applicants will be screened at our expense for criminal
background histories by state and/or federal agencies. Persons who have been convicted of any felony offense or misdemeanor offenses involving drugs,
child abuse, assault or any violent behavior are not eligible to volunteer at Boulder Community Hospital. There are no exceptions.
Have you ever been convicted of a felony or misdemeanor offense No Yes
Have you ever been terminated from volunteering No Yes
Boulder Community Hospital reserves the right to do drug screening at any time, if necessary.
I certify that the statements made in this volunteer application are true and correct. I understand that this information may be disclosed to any party with legal and
proper interest and I release Boulder Community Hospital from any liability whatsoever for supplying such information. I authorize you to make any investigation of
my personal history. I understand that I will not be paid for my services as this is strictly volunteer work.
Applicant’s Signature _________________________________________________________________
Parent /Guardian (if younger than 18 years old) _______________________________________________
Date _______________________________
Date _______________________________
In order to give you more information during your interview, please check your areas of interest.
Direct Patient Services
Surgery Waiting Room
Specialty Services
Pet Therapy Program
Staff Support Services
Accounting
Information Desk
KNITTING
Administration
Family Resource Library (4N) Afghans
Billing Department
Cardiac Telemetry
Baby Booties
Business Office
Medical Surgical Floor (4N) Baby Hats
Managed Care
Oncology
Medical Records
SEWING SERVICE
Orthopedics
Public Information
OT—Walker Bags
Women/Family Services
Radiology Clerical
__ Labor/Delivery
Volunteer Services
__ Postpartum
__ Pediatrics
__ Newborn Hearing
__ Newborn Photographs
Emergency Room
Recovery Room
Intensive Care
Surgery Center
Mapleton Center
__ Physical Therapy
__ Sports Medicine Center
__ Rehab Nursing
Radiation Therapy Center
Community Medical Center
SPECIAL PROGRAMS
Blood Drives
Diabetes Support Group
Flu Clinics
Hearing Screenings
Cancer Screenings
SMALL BUSINESS
Broadway Gift Shop
Maple Leaf Gift Shop
RESEARCH & DEVELOPMENT
_________________________
If you have a special skill that you
want to share, please list below.
_________________________
_________________________
_________________________
Skills You Wish to Share
CLERICAL SKILLS
Data Entry
Copying
Filing
Statistics
Bookkeeping
Typing (WPM _____________)
Errands
Greeting People
Calligraphy
Other ___________________
COMMUNICATIONS
Public Speaking
Tours
Teaching
Storytelling
Answering Phones
Greeting Patients
Foreign Language:
_______________________
Patient Representative
Other ___________________
Preferred Shift Mornings Afternoons Evenings All Day
Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Service-Campus-Day/Time _______________________________ FOR OFFICE USE ONLY C F T
Orientation Date _______________________________________ MMR Doc. (Received) _________________________________________________
Orientation Letter Sent __________________________________ Rubella Doc./Titre ___________________________________________________
Job Description Given___________________________________ TB Skin Test Read/Results______________________________________________
Made Contact with Department/Date_________________________
Additional Comments _____________________________________________________________________________________________________
____________________________________________________________________________________________________________________