VOLUNTEER APPLICATION FORM - Boulder Community Hospital

Boulder Community Hospital
P.O. Box 9019 Boulder, Colorado 80301-9019 Office 303-440-2137 Fax 303-440-2138 E-mail volunteers@bch.org
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 Volunteer Only Adult Volunteer (18+) College Student Teen Volunteer (14-17)
Confidential/Personal Information
Birthday: (Month/Day/Year)________________ Social Security Number _____________________________________________
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 any special assistance or accommodations to perform your volunteer duties, you may indicate those needs at this time,
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 # ____________________________
City _____________________________________________ State ______________________________ Zip Code ____________________
Prior Volunteer Service
Where else have you volunteered ______________________________________________________________________________________________
Dates _______________Agency__________________________ Duties _____________________________________________
Department ______________________________ Supervisor__________________________Phone _______________________
Dates _______________Agency__________________________ Duties _____________________________________________
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(s)___________
Interests and 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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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 any 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 our patients to be of the utmost importance. All volunteers 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 Yes No
Have you ever been terminated from volunteering Yes No
Boulder Community Hospital reserves the right to do drug screening at any time, if necessary.
Authorization
By signing below, I hereby voluntarily authorize Boulder Community Hospital Volunteer Services to obtain a consumer report
about me from a consumer-reporting agency and to consider this information when making decisions regarding my volunteering
at Boulder Community Hospital.
For explanation purposes, a “consumer reporting agency” is a person or business which, for monetary fees, dues, or
cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on
consumers for the purpose of furnishing consumer reports to others, such as Boulder Community Hospital.
A “consumer report” means any written, oral or other communication of any information by a consumer-reporting agency
bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics,
or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a
factor in establishing your eligibility for volunteer purposes.
Please Print or Type
List other names under which records may be found (i.e. Maiden Name) ___________________________________________
Driver’s License Number ______________________ State of Issue _____________________________________________
Please list all addresses for the past 5 years. Use another sheet if necessary.
Previous Address ______________________________________________________________________________________
Street City State Zip Dates
Previous Address ______________________________________________________________________________________
Street City State Zip Dates
Previous Address ______________________________________________________________________________________
Street City State Zip Dates
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 under 18 years old)__________________________________
Date _____________________________
Date _____________________________
In order to give you more information during your interview, please check your areas of interest:
Direct Patient Services Specialty Services Staff Support Services Skills You Wish to Share

BROADWAY CAMPUS BROADWAY CAMPUS BROADWAY CAMPUS CLERICAL SKILLS
Cancer Care Pet Therapy Program Accounts Payable Data Entry
Cardiac Telemetry (3W/3N) Coffee Cart Dispatch Copying
Emergency Department Flutterby Magazine Cart Imaging Clerical Filing
Intensive Care Unit Surgery Statistics
Med/Surg (2N/2 Central) FOOTHILLS CAMPUS Radiation Therapy Bookkeeping
Orthopedics/Neuro (2W) Volunteer Services Typing (WPM____)
Patient Representative Pet Therapy Program Greeting People
Post Anesthesia Care Unit FOOTHILLS CAMPUS Calligraphy
Surgery Waiting Room MAPLETON CAMPUS
Lactation Specialist
COMMUNICATIONS
FOOTHILLS CAMPUS Pet Therapy Program Surgery
Coffee Kiosk
Tours
Concierge
Answering Phones
Courtesy Desk
OFF-SITE (AT HOME)
Emergency/ICU
Newborn Hearing Knitting If you have any special
Newborn Photography
skills that you would
Mom/Baby-SCN Afghans like to share, please
Pediatrics Baby Booties list below
Post Anesthesia Care Unit Baby Hats ___________________
MAPLETON CAMPUS Sewing ___________________
Physical Therapy Walker Bags ___________________
Rehab Nursing
Pet Therapy Capes
Sports Medicine Center
OUTREACH
LifeLine Response System
55+ Wellness Clinics
EPISODIC PROGRAMS
Blood Drives
Diabetes Support Group
Flu Clinics
SMALL BUSINESS
Broadway Gift Shop
Foothills Gift Shop
Maple Leaf Gift Shop
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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/titer ____________________________
Job description given __________________________________ TB skin test read/results _____________________
Made contact with department/date _______________________ Have you had chicken pox Yes No
Additional comments
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10/99; 2/0, 9/01, 9/02, 8/03, 3/04, 08/05