VOLUNTEER APPLICATION FORM - Boulder Community Hospital

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