McLaren Lapeer Region Junior Volunteer Application Form - Online

McLaren Lapeer Region
Junior Volunteer Application Form

*Indicates required information

Last Name: *

First Name: *

Middle Initial:

Address: *

City, State, Zip: *

Daytime Phone: *

Evening Phone:

Cell Phone:

Email: *

Gender: *

Male

Female

Michigan Drivers License Number: *

Date of Birth: *

Age (minimum age requirement for junior volunteer 16 yrs old): *

Are you aware of any medical, physical or mental handicap that would affect your ability to perform volunteer duties?

Yes

Explain:

Are you presently engaged in any activity at McLaren Lapeer Region?

yes

If yes, describe:

Are you currently employed?

yes

If yes, where (include employer phone and position):

Education

High School

College

Other

If other, describe:

Are you presently a student?

yes

if yes, where: :

Grade: *

Counselor:

Interests:

Are you preparing for any special career?

yes

If yes, describe:

Please list any special skills or abilities you possess?

typing	filing
sign language	other

If other:

Community Affiliations:

I am interested in becoming a volunteer because:

Have you ever been a volunteer?

yes

If so, when:

References (Other than relatives)

Name: *

Phone: *

Street Address: *

City, State, Zip: *

Name: *

Phone: *

Street Address: *

City, State, Zip: *

Emergency Contact:

Name: *

Relationship to you: *

Phone: *

Address: *

City, State, Zip: *

Preferred Service and Time

Service Area Preferred:

Emergency Room Gift Shop
Escort Service Patient Relations
Info Desk Fundraising-Sales-Special Events

Days Preferred:

Monday-Friday
Weekends
Holidays

Hours Preferred:

Mornings
Afternoons
Evenings

BACKGROUND CHECK (To protect your privacy, this form will only be seen by MLR Volunteer Services staff)

Please indicate any other name(s) ever used:

Have you event been convicted of a felony or misdemeanor?

yes no

If yes, please explain:

I GIVE MCLAREN LAPEER REGION PERMISSION TO CHECK MY CRIMINAL HISTORY WITH MICHIGAN LAW ENFORCEMENT AGENCIES, AND TO SEARCH MY HISTORY FOR INCIDENTS OF FRAUD WITH THE FRAUD AND ABUSE CONTROL INFORMATION DATABASE. I AUTHORIZE MCLAREN LAPEER REGION AND ITS AFFILIATES OR IT’S DESIGNATED AGENTS TO MAKE WHATEVER INQUIRES IT MAY DEEM NECESSARY IN CONNECTION WITH MY VOLUNTEER APPLICATIONS. AS PART OF SUCH INQUIRES, MCLAREN LAPEER REGION HAS MY PERMISSION TO CONTACT PERSONS WHO MAY HAVE INFORMATION RELATING TO MY SUITABILITY FOR VOLUNTEER WORK. I FURTHER AUTHORIZE MCLAREN LAPEER REGION, IN ITS SOLE DISCRETION TO FURNISH COPIES OF THIS AUTHORIZATION AND MY VOLUNTEER APPLICATION TO ANY PERSONS IN CONNECTION WITH THE ABOVE PROCESS.

I UNDERSTAND THAT MY ENROLLMENT AS A VOLUNTEER IS CONTINGENT UPON SUCCESSFUL COMPLETION OF THE APPLICATION PROCESS. FOR MY CRIMINAL HISTORY TO BE VERIFIED AND TO HAVE MY HISTORY SEARCHED FOR FRAUD AND ABUSE. I AGREE TO RELEASE MCLAREN LAPEER REGION, IT’S AFFILIATES, AND ALL PARTIES FROM ANY LIABILITY FOR ANY DAMAGES THAT MAY RESULT FROM FURNISHING SUCH INFORMATION.

IF I AM SELECTED AS A MCLAREN LAPEER REGION CENTER VOLUNTEER I AGREE TO ABIDE BY ALL HOSPITAL RULES, REGULATIONS AND EXPECTATIONS. I UNDERSTAND THAT EITHER PARTY MAY CANCEL THIS RELATIONSHIP AT ANY TIME.

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO INFORM MCLAREN LAPEER REGION OF ANY CHARGES.

Applicant Signature: *

Date:

Note: A criminal history will not necessarily disqualify an applicant. A criminal record is one piece of information that will be considered in determining the appropriates of an individual to be a McLaren Lapeer Region Volunteer

Students are responsible for their own transportation to McLaren Lapeer Region. Students will be required to work one day per week. I understand the importance of confidentiality for all patients and will stress the importance of this with my child. Students will receive orientation explaining COMPLIANCE & HIPPA BASICS.

I understand that all students will be required to have a TB test prior to participating in the program. This will be given by hospital staff, following established policies and procedures. There will be no cost incurred for the TB test. Students are required to present their immunization records to the employee health nurse.

II HERBY GIVE CONSENT FOR THE ABOVE NAMED APPLICANT TO SERVE AS A VOLUNTEER AT MCLAREN LAPEER REGION. I ALSO AUTHORIZE MCLAREN LAPEER REGION AND THEIR PHYSICIANS TO RENDER MEDICAL, HOSPITAL OR PERSONNEL HEALTH SERVICES TREATMENT AND/OR EXAMINATION INCLUDING TB TESTING TO THE ABOVE NAMED INDIVIDUAL.

Parent or Guardian Signature: *

Date:

AS A VOLUNTEER, YOU WILL HAVE THE OPPORTUNITY TO LEARN A GREAT DEAL ABOUT THE HEALTH CARE INDUSTRY. THE EXPERIENCE THAT YOU ACQUIRE MAY BE OF VALUE IN THE FUTURE. HOWEVER, THAT FACT THAT YOU HAVE BEEN ACCEPTED AS A VOLUNTEER BY MCLAREN LAPEER REGION IS NOT TO BE CONSTRUED IN ANY MANNER AS A GUARANTEE OF FUTURE EMPLOYMENT OR A COMMITMENT THAT YOU MAY BE CONSIDERED FOR OR OFFERED EMPLOYMENT BY THE MEDICAL CENTER AT SOME FUTURE DATE.

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