Online Volunteer Application For McLaren Northern Michigan

Volunteer Application

McLaren Northern Michigan
Volunteer Services Application Form

Note: Fields marked with an * indicates required field

I hereby request to become a member of the Volunteer Services Department at McLaren Northern Michigan and will abide by all hospital and department policies. I am willing to volunteer and:

am 18 years of age or older,
agree to be trained and oriented,
wear a volunteer uniform and ID badge, accurately record my service hours,
receive a TB test, if I do not have documentation of receiving one in the past 12 months; an annual Influenza Vaccination (if volunteering during the months of October – April); and comply with any other mandatory requirements,
I will be responsible and regular in my attendance and will inform my department of necessary absences,
services are donated without contemplation of compensation or future employment and does not constitute an employment contract,
my assignment can be terminated at any time with or without notice and for any reason,
I will respect the need for safety, infection control, and patient confidentiality,
I understand that my volunteer work experience will be recorded and held for future reference. I give my permission for release of this information,

donate 50 unpaid hours of service within a one-year period .

Last Name: *

First Name: *

Middle Initial:

Street Address: *

City - State - Zip Code: *

Phone: *

E-mail Address: *

Are you at least 18 years of age? *

yes

Are you eligible to work in the U.S.? *

yes

High School Graduate?

yes

Education/Training

Highest Grade Attended:

College or Number of years attended:

Degree(s) earned:

Associate

Bachelors

Masters

Phd

Work Experience

Are you currently employed?

yes

Retired from or currently employed at?

Days and times you work:

Business Phone:

Does your employer have a volunteer giving program?

yes

Do not know

Previous Work Experience:

Volunteer Experience

1st place of experience:

Role:

Date:

2nd place of experience:

Role:

Date:

3rd Place of experience:

Role:

Date:

Local person to be contacted in case of illness/emergency:

Name: *

Relationship to you: *

Phone: *

Address: *

City, State, Zip: *

References (Please list two adults over 21 years who are not relatives and who have known you for at least two years.)

Name: *

Phone: *

Street Address: *

City, State, ZipCode: *

Name: *

Phone: *

Street Address: *

City, State, ZipCode: *

Volunteer Profile

Please give a brief summary of your background:

Reasons for wanting to volunteer:

How did you learn about volunteer opportunities?

Is this a required volunteer assignment?

yes

If yes, number of hours needed:

If yes, deadline:

Times and days available:

Areas of Interests:

Other skills and interests:

Any particular volunteer activity or department you would like to try?

Any volunteer activity you would not want to be called upon to do?

Have you event been convicted of a crime (other than traffic violation) or misdemeanor?

yes

If yes, please indicate the nature and date of occurrence:

Please read the following information prior to submitting your application:

Infection Control

Proper hand hygiene helps prevent the spread of infections from one person to another. Hand hygiene products, which contain a special antibacterial agent, are available in wall dispensers in the work areas and cafeteria.

Hazardous Materials

Potentially hazardous chemicals and materials are used in certain areas as part of the daily operation of a department. Material Safety Data Sheets (MSDS) which describe the hazard and handling instructions for all chemical products are available for your review on request.

Tobacco Free Campus

Smoking and all tobacco products are prohibited in all McLaren Northern Michigan facilities and its adjacent grounds.

Dress Code

Please adhere to the following dress code, unless otherwise directed:

Comfortable closed-toe shoes with socks or hose, no bare legs
Shirt (no slogans) with slacks or skirt (no jeans, sagging pants, t-shirts, low-cut or midriff-baring shirts;
Skirts may not be more than 2” above knee)
Minimum jewelry (no facial piercing jewelry),
No visible tattoos
No fragrance or smoking odor on clothing
Well-groomed hair

Health Requirements

You must be in good health without fever (99.0 or less) and/or symptoms of cold, flu or other illness.

Confidentiality

Please read and sign the below confidentiality agreement.

Statement of Understanding
I have read and understand the information above. Should I need medical attention during or as a result of volunteering, I assume full responsibility for any treatments deemed necessary. I assume responsibility of all medical costs which result and release McLaren Northern Michigan of all liability. I give the facility at which I am providing volunteer services permission to release my telephone number or contact instructions to the requested department. While I am volunteering my service at any site under McLaren Northern Michigan, I realize that all health care information, patient / resident care and records are a confidential matter. All information exchanged while I am volunteering must be held in the strictest confidence. My typed name below shall have the same force and effect as my written signature.
Applicant Signature: *
Date:

Statement of Confidentiality

Each of our patients and employees has the right to expect that we will keep any knowledge we have about them in the strictest confidence. It is our obligation under the law and the codes, regulations and certifications under which we operate, to honor this expectation. Equally important, respecting confidentiality is part of our obligation to provide the most comfortable and caring environment for our patients.

We live at a time when personal information is recorded in many forms. It may be on paper, but it may also be found on a computer screen, voice mail, cellular telephones or another modern convenience. This data is all subject to the same rules.

Our expectation is that you will keep all patient and employee information to yourself or share it only with others who have a work related or legal right to know. You should never share any information with anyone else, including spouses or coworkers. Passwords, to access patient and employee information, must not be shared.

Finally, we remind you that the organization will not tolerate violations of this standard. The established rules call for prompt and severe discipline for a breach of confidentiality. Please understand that the Confidentiality of Health and Medical Record Information policy RI.108 will be strictly enforced.

Full Name - my typed name shall have the same force and effect as my written signature: *

Date: *

My typed name below shall have the same force and effect as my written signature.

Authorization and Release

In connection with my opportunity to participate in any program affiliated with McLaren Northern Michigan, I understand that information may be requested as to my character and other personal history. I further understand that you will be requesting information regarding my criminal history and other public records. I agree that any false information may subject me to removal from programs at McLaren Northern Michigan. It is the policy of McLaren Northern Michigan not to employ or retain persons in positions of trust who have demonstrated a propensity to engage in illegal activities.

I hereby authorize and release from all liability without reservation, McLaren Northern Michigan and any law enforcement agency, administrator, state/federal agency, institution, insurance company, or person gathering or furnishing the above information.

Full Name - my typed name shall have the same force and effect as my written signature: *
Date: *
Past Proper Name(s) - i.e. Maiden Name:
Date of Birth: *
Current Address - (include city, state, zip): *
Last 4 digits of Social Security Number: *

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Volunteer Application

McLaren Northern Michigan Volunteer Services Application Form

McLaren Northern Michigan
Volunteer Services Application Form